2019 cigna-healthspring rx comprehensive drug list …then look under the category name for your...

Plan coveredCigna-HealthSpring Rx Secure-Extra (PDP)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT ALL OF THE DRUGS WE COVER IN THIS PLAN.

2019 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring Rx is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring Rx depends on contract renewal.HPMS Approved Formulary File Submission ID 19144, Version Number 17 INT_19_65288_C_Final_7n Populated Template 07312018

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What is the Cigna-HealthSpring Rx Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna-HealthSpring Rx in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring Rx will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring Rx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2019 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic equivalent of the drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect customers currently taking the drug.) Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect customers currently taking the drug:• New generic drugs. We may immediately remove a brand

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but immediately move

it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the following section entitled “How do I request an exception to the Cigna-HealthSpring Rx Drug List?”

• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect customers currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines and/or studies. If we remove drugs from our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 30 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 30-day supply of the drug.

The enclosed drug list is current as of December 2019. To get updated information about the drugs covered by Cigna-

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring Rx. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Rx Secure-Extra (PDP).

This document includes a list of the drugs (formulary) for our plans, which is current as of December 2019. For an updated drug list, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

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HealthSpring Rx, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 19. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 19. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 64. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

What are generic drugs?Cigna-HealthSpring Rx covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Cigna-HealthSpring Rx requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna-HealthSpring Rx before you fill these prescriptions. If you don’t get approval, Cigna-HealthSpring Rx may not cover the drug.

• Quantity Limits: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx will cover. For example, Cigna-HealthSpring Rx allows for 1 tablet per day for simvastatin 10mg. This applies to a standard one-

month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna-HealthSpring Rx requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna-HealthSpring Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna-HealthSpring Rx will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 120 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not “opioid naïve”) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 19. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring Rx to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring Rx drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

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• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna-HealthSpring Rx coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Check the Drug Tier and Cost-Share Tables to see if your plan offers copay savings with mail order. You may be able to save up to 17% on your copays with mail order.

• Explore whether the ‘CMS Extra Help’ program may offer additional financial support for your medications.

• If your medication is not covered in the Cigna-HealthSpring Rx drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring Rx does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna-HealthSpring Rx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring Rx.

• You can ask Cigna-HealthSpring Rx to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Cigna-HealthSpring Rx Drug List?You can ask Cigna-HealthSpring Rx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not in our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that we will cover. If your

drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna-HealthSpring Rx will only approve your request for an exception if the alternative drugs included in our drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of

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medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring Rx will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring Rx’s Drug ListThe comprehensive drug list that begins on page 19, provides coverage information about all of the drugs covered by Cigna-HealthSpring Rx. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 64. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., simvastatin).

The information in the Requirements/Limits column tells you if Cigna-HealthSpring Rx has any special requirements for coverage of your drug. This plan offers additional prescription drug coverage in the coverage gap. Please refer to your Evidence of Coverage to see this coverage and for more information.We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 19 along with the amount dispensed per the days supplied. (For example: simvastatin 10mg QL 30/30; this means the drug simvastatin 10mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna-HealthSpring Rx prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna-HealthSpring Rx, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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Cigna-HealthSpring Rx Secure-Extra (PDP)

Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing

Preferred Mail Order

Cost-Sharing

Standard Mail Order

Cost-Sharing

Long-term Care 31 days

Out-of-network 30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

ALABAMA

Tier 1: Preferred Generic Drugs $4 / $8 / $12 $9 / $18 / $27 $4 / $8 / $10 $9 / $18 / $27 $9

Tier 2: Generic Drugs $10 / $20 / $30 $15 / $30 / $45 $10 / $20 / $25 $15 / $30 / $45 $15

Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $105 $47 / $94 / $141 $47

Tier 4: Non-Preferred Drugs 50% 50% 50% 50% 50%

Tier 5: Specialty Tier 31% (30 days) 31% (30 days) 31% (30 days) 31% (30 days) 31%

Tier 6: Select Care Drugs $6 / $12 / $18 $11 / $22 / $33 $6 / $12 / $15 $11 / $22 / $33 $11

ALASKA







* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billed charge and our typical Standard Retail pharmacy billed costs.

To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan in which you are currently enrolled or would like to enroll.Cigna-HealthSpring Rx uses preferred network pharmacies. See your Pharmacy Directory or visit www.CignaHealthSpring.com to search for a preferred retail or mail-order pharmacy near you.

Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Tier 6 is for Cigna-HealthSpring Rx Secure-Extra (PDP) plans only and is referred to as Select Care Drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna-HealthSpring Rx is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers,

and some generic medications may be in Tier 3, Tier 4, Tier 5 or Tier 6. Keep in mind that the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



ARIZONA







ARKANSAS







CALIFORNIA







COLORADO








7



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



CONNECTICUT







DELAWARE







DISTRICT OF COLUMBIA







FLORIDA







8


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



GEORGIA







HAWAII







IDAHO







ILLINOIS








9



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



INDIANA







IOWA







KANSAS







KENTUCKY







10


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



LOUISIANA







MAINE







MARYLAND







MASSACHUSETTS








11



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



MICHIGAN







MINNESOTA







MISSISSIPPI







MISSOURI







12


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



MONTANA







NEBRASKA







NEVADA







NEW HAMPSHIRE








13



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



NEW JERSEY







NEW MEXICO







NEW YORK







NORTH CAROLINA







14


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



NORTH DAKOTA







OHIO







OKLAHOMA







OREGON








15



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



PENNSYLVANIA







RHODE ISLAND







SOUTH CAROLINA







SOUTH DAKOTA







16



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



TENNESSEE







TEXAS







UTAH







VERMONT







17



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



VIRGINIA







WASHINGTON







WEST VIRGINIA







WISCONSIN







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My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-222-6700, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring Rx


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



WYOMING







Drug List Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.PA – This drug requires prior authorization

QL – This drug has quantity limitsST – This drug has step therapy requirementsGenerally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 18.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsacetaminophen/codeine oral soln

2 NDS QL

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MORPHINE SULFATE INJ 10MG/ML

4 B/D PA NDS QL(240/30)


4 B/D PA NDS QL(250/30)


4 B/D PA NDS QL(480/30)


4 B/D PA NDS QL(1200/30)

morphine sulfate oral soln 100mg/5ml

2 NDS QL(240/30)


2 NDS QL(700/30)


2 NDS QL(900/30)

MORPHINE SULFATE TABS 3 NDS QL(120/30)nalbuphine hcl inj 20mg/ml 4 NDS QL(90/30)nalbuphine hcl inj 10mg/ml 4 NDS QL(180/30)oxycodone hcl conc 4 NDS QL(120/30)oxycodone hcl tabs 3 NDS QL(180/30)oxycodone hydrochloride oral soln

4 NDS QL(1200/30)

oxycodone hydrochloride tabs 3 NDS QL(180/30)oxycodone/acetaminophen tabs 325mg; 10mg

4 NDS QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

4 NDS QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

4 NDS QL(360/30)

oxycodone/aspirin 4 NDS QL(180/30)oxycodone/ibuprofen 4 NDS QL(28/30)tramadol hcl 2 NDS QL(240/30)tramadol hydrochloride/acetaminophen

4 NDS QL(240/30)

Anesthetics

Local Anestheticsglydo 3 PAlidocaine hcl external soln 2 PAlidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

4

lidocaine hcl jelly gel 3 PAlidocaine hcl mouth/throat soln 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

endocet tabs 325mg; 10mg 4 NDS QL(180/30)endocet tabs 325mg; 7.5mg 4 NDS QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

4 NDS QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

4 B/D PA NDS

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

4 PA NDS QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

5 PA NDS QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln 325mg/15ml; 7.5mg/15ml

4 NDS QL(2700/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg

4 NDS QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg

4 NDS QL(360/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

3 NDS QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

3 NDS QL(360/30)

hydrocodone/ibuprofen 4 NDS QL(150/30)hydromorphone hcl dosette 4 NDShydromorphone hcl inj 4 NDShydromorphone hcl liqd 3 NDS QL(1200/30)hydromorphone hcl tabs 8mg 4 NDS QL(120/30)hydromorphone hcl tabs 2mg, 4mg

4 NDS QL(180/30)

lorcet 4 NDS QL(360/30)lorcet hd 4 NDS QL(180/30)lorcet plus tabs 325mg; 7.5mg 4 NDS QL(180/30)MORPHINE SULFATE INJ 50MG/ML, 5MG/ML

4 B/D PA NDS

morphine sulfate inj 1mg/ml 4 B/D PA NDSmorphine sulfate inj 0.5mg/ml, 1mg/ml

4 B/D PA NDS QL(180/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antibacterials

Aminoglycosidesamikacin sulfate 4gentak 2gentamicin sulfate crea 4gentamicin sulfate inj 4gentamicin sulfate oint 3gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric 4gentamicin sulfate/0.9% sodium chloride

4

isotonic gentamicin 4neomycin sulfate 2paromomycin sulfate 4streptomycin sulfate 4tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

4

tobramycin sulfate ophthalmic soln

2

Antibacterials, OtherALCOHOL PREP PADS 6bacitracin inj 4bacitracin ophthalmic oint 4bacitracin/polymyxin b 2chloramphenicol sodium succinate

4

clindacin etz pledgets 2clindacin-p 2clindamycin hcl caps 2clindamycin phosphate crea 4clindamycin phosphate external soln

4

clindamycin phosphate gel 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lidocaine hcl prsy 3 PAlidocaine hcl viscous 2lidocaine oint 4 PA QL(50/30)lidocaine ptch 4 PA QL(90/30)lidocaine viscous 2lidocaine/prilocaine crea 4 PA

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 4disulfiram 4naltrexone hcl 2Opioid Dependence Treatmentsbuprenorphine hcl subl 4 PA QL(90/30)buprenorphine hcl/naloxone hcl 4 QL(90/30)buprenorphine hydrochloride/naloxone hydrochloride film

4 QL(90/30)

SUBOXONE 3 QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

3 QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 QL(90/30)

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hydrochloride er (sr) 2 QL(60/30)CHANTIX 3 QL(56/28)CHANTIX CONTINUING MONTH PAK

3 QL(56/28)

CHANTIX STARTING MONTH PAK

3 QL(56/28)

NICOTROL INHALER 4 QL(1008/90)NICOTROL NS 4 QL(30/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 4polymyxin b sulfate/trimethoprim sulfate

2

rosadan 3silver sulfadiazine 4SIVEXTRO TABS 5 NDS QL(6/30)SSD 4SYNERCID 5 NDStigecycline 5 NDStrimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

vancomycin 4vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 5gm, 750mg

4

vancomycin hydrochloride caps 125mg

4 QL(40/10)

vancomycin hydrochloride caps 250mg

4 QL(80/10)

VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML

4

vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg

4

vancomycin hydrochloride/dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml

4

vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml

4

vandazole 4XIFAXAN TABS 550MG 5 PA NDS QL(90/30)Beta-lactam, Cephalosporinscefaclor 4cefaclor er 4cefadroxil 2CEFAZOLIN 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin phosphate in d5w 4clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml

4

clindamycin phosphate lotn 4clindamycin phosphate swab 2clindamycin/sodium chloride 4colistimethate sodium 4DAPTOMYCIN INJ 350MG 5 B/D PA NDSdaptomycin inj 500mg 5 B/D PA NDSFIRVANQ 4 QL(300/10)lincomycin hcl 4linezolid inj 4linezolid susr 5 NDS QL(1800/30)linezolid tabs 5 NDS QL(60/30)methenamine hippurate 4metronidazole crea 3metronidazole gel 3metronidazole in nacl 0.79% 4metronidazole inj 500mg/100ml; 0.79%

4

metronidazole lotn 3metronidazole tabs 2metronidazole vaginal 4mupirocin crea 4mupirocin oint 2neo-polycin 2neo-polycin hc 3neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

4

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

4

nitrofurantoin 4nitrofurantoin macrocrystals caps 25mg

4

nitrofurantoin macrocrystals caps 100mg, 50mg

2

nitrofurantoin monohydrate 2

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

imipenem/cilastatin inj 250mg; 250mg

3

INVANZ 4meropenem 4meropenem/sodium chloride 4Beta-lactam, Penicillinsamoxicillin caps 1amoxicillin chew 2amoxicillin susr 1amoxicillin tabs 2amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

4

ampicillin 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

4

BICILLIN L-A 4dicloxacillin sodium 2nafcillin sodium 4oxacillin sodium 4penicillin g potassium 4penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

2

pfizerpen inj 20000000unit, 5000000unit

4

piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm

4

piperacillin/tazobactam 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg

4

cefazolin sodium/dextrose inj 2gm; 3%

4

cefdinir 4cefepime 4cefepime/dextrose 4cefixime caps 4 QL(30/30)cefixime susr 4cefotaxime sodium inj 1gm, 500mg

4

cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil 4cefprozil 2ceftazidime 4ceftazidime/dextrose 4ceftriaxone in iso-osmotic dextrose

4

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

4

cefuroxime axetil 3cefuroxime sodium 4cephalexin caps 250mg, 500mg 2cephalexin susr 2tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5 NDSBeta-lactam, OtherAZACTAM 4aztreonam inj 1gm 4aztreonam inj 2gm 5 NDScefotetan 4ertapenem 4ertapenem sodium 4imipenem/cilastatin inj 500mg; 500mg

4

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciprofloxacin hcl tabs 100mg 4ciprofloxacin hydrochloride 2ciprofloxacin i.v.-in d5w 4ciprofloxacin susr 4levofloxacin in d5w 4levofloxacin inj 4levofloxacin oral soln 2levofloxacin tabs 500mg 2levofloxacin tabs 250mg, 750mg

2 QL(30/30)

moxifloxacinhydrochloride/sodium hydrochloride

4

moxifloxacin hcl 4moxifloxacin hydrochloride ophthalmic soln

3

moxifloxacin hydrochloride tabs 4ofloxacin ophthalmic soln 2ofloxacin otic soln 4ofloxacin tabs 2SulfonamidesBLEPHAMIDE 4BLEPHAMIDE S.O.P. 4sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium lotn 4sulfacetamide sodium ophthalmic soln

2

sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 4sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

4

sulfamethoxazole/trimethoprim tabs

1

Tetracyclinesdoxy 100 4doxycycline hyclate caps 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

4

MacrolidesAZASITE 3azithromycin inj 4azithromycin pack 3azithromycin susr 200mg/5ml 4 QL(90/30)azithromycin susr 100mg/5ml 4 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin 4clarithromycin er 4ery 4ERY-TAB 4ERYPED 400 5 NDSERYTHROCIN LACTOBIONATE

4

erythrocin stearate 4erythromycin base 4ERYTHROMYCIN DR 4erythromycin ethylsuccinate susr 200mg/5ml

4

ERYTHROMYCIN ETHYLSUCCINATE SUSR 400MG/5ML

5 NDS

erythromycin ethylsuccinate tabs

4

erythromycin external soln 2erythromycin gel 4erythromycin oint 2QuinolonesAVELOX 4BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin hcl tabs 750mg 2

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levetiracetam tabs 2levetiracetam/sodium chloride 4magnesium sulfate in d5w 4 B/D PANAYZILAM 4 PA QL(10/30)roweepra 2roweepra xr tb24 750mg 4 QL(120/30)roweepra xr tb24 500mg 4 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 3ethosuximide 4LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)pregabalin caps 225mg, 300mg 3 QL(60/30)pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg

3 QL(90/30)

pregabalin oral soln 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam susp 4 QL(480/30)clobazam tabs 4 QL(60/30)clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

4 QL(90/30)

clonazepam odt tbdp 1mg 4 QL(120/30)clonazepam odt tbdp 2mg 4 QL(300/30)clonazepam tabs 0.5mg 2 QL(90/30)clonazepam tabs 1mg 2 QL(120/30)clonazepam tabs 2mg 2 QL(300/30)DIACOMIT CAPS 500MG 5 PA NDS QL(180/30)DIACOMIT CAPS 250MG 5 PA NDS QL(360/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxycycline hyclate tabs 100mg, 20mg

2

doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 4minocycline hcl caps 2minocycline hcl tabs 4minocycline hydrochloride caps 100mg, 50mg

2

mondoxyne nl caps 100mg 2 QL(60/30)mondoxyne nl caps 75mg 3 QL(60/30)morgidox 1x100mg caps 2morgidox 1x50mg 4morgidox 2x100mg caps 2NUZYRA INJ 4 QL(15/14)NUZYRA TABS 4 QL(30/14)tetracycline hydrochloride 4

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

5 NDS QL(30/30) ST

APTIOM TABS 600MG 5 NDS QL(60/30) STBRIVIACT INJ 5 NDS QL(600/30)BRIVIACT ORAL SOLN 5 NDS QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 NDS QL(60/30)

BRIVIACT TABS 100MG 5 NDS QL(120/30)EPIDIOLEX 5 PA NDSFYCOMPA SUSP 4 PA QL(720/30)FYCOMPA TABS 4 PA QL(30/30)levetiracetam er tb24 750mg 4 QL(120/30)levetiracetam er tb24 500mg 4 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Sodium Channel AgentsBANZEL SUSP 5 PA NDS

QL(2400/30)BANZEL TABS 200MG 5 PA NDS QL(60/30)BANZEL TABS 400MG 5 PA NDS QL(240/30)carbamazepine 2carbamazepine er cp12 2carbamazepine er tb12 3DILANTIN 4DILANTIN INFATABS 4epitol 2fosphenytoin sodium 4oxcarbazepine susp 2oxcarbazepine tabs 3PEGANONE 4phenytoin 2phenytoin infatabs 2phenytoin sodium 4phenytoin sodium extended 2VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Cholinesterase Inhibitorsdonepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)donepezil hydrochloride tabs 5mg

2 QL(30/30)

donepezil hydrochloride tabs 10mg

2 QL(60/30)

galantamine hydrobromide er 4 QL(30/30)galantamine hydrobromide oral soln

4 QL(200/30)

galantamine hydrobromide tabs 4 QL(60/30)rivastigmine tartrate 4 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 3 PA QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DIACOMIT PACK 500MG 5 PA NDS QL(180/30)DIACOMIT PACK 250MG 5 PA NDS QL(360/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 3 QL(5/30)diazepam rectal gel gel 10mg 3 QL(20/30)diazepam rectal gel gel 20mg 3 QL(40/30)divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2gabapentin tabs 600mg 2 QL(180/30)GABITRIL TABS 12MG, 16MG 4 STGRALISE 3GRALISE STARTER 3 QL(156/365)ONFI SUSP 4 QL(480/30)ONFI TABS 10MG, 20MG 4 QL(60/30)phenobarbital elix 4 QL(1500/30)phenobarbital tabs 4 QL(120/30)primidone 2SABRIL TABS 5 PA NDS QL(180/30)tiagabine hydrochloride 4 STvalproate sodium inj 100mg/ml 4valproic acid 2vigabatrin pack 5 PA NDS QL(200/30)vigabatrin tabs 5 PA NDS QL(180/30)vigadrone 5 PA NDS QL(200/30)Glutamate Reducing Agentsfelbamate susp 5 NDSfelbamate tabs 4lamotrigine 2lamotrigine er 4lamotrigine odt 4topiramate 2

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

citalopram hydrobromide tabs 40mg

1 QL(30/30)


1 QL(60/30)

desvenlafaxine er 4 QL(30/30)duloxetine hcl cpep 20mg 2 QL(60/30)duloxetine hydrochloride cpep 60mg

2 QL(60/30)

duloxetine hydrochloride cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln 4 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30) STFETZIMA TITRATION PACK 4 QL(56/365) STfluoxetine dr 2 QL(4/28)fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hydrochloride caps 10mg

2 QL(30/30)

fluoxetine hydrochloride oral soln

2 QL(600/30)

fluoxetine hydrochloride tabs 10mg

2 QL(30/30)

fluoxetine hydrochloride tabs 20mg

2 QL(120/30)

fluvoxamine maleate tabs 25mg, 50mg

3 QL(30/30)

fluvoxamine maleate tabs 100mg

3 QL(90/30)

olanzapine/fluoxetine 4 QL(30/30)paroxetine hcl tabs 10mg 1 QL(30/30)paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hydrochloride tabs 20mg

1 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

memantine hcl tabs 5mg 3 PA QL(90/30)memantine hcl titration pak 3 PA QL(49/28)memantine hydrochloride er 3 PA QL(30/30)memantine hydrochloride oral soln

4 PA QL(360/30)

Antidepressants

Antidepressants, Otherbupropion hcl tabs 100mg 2 QL(120/30)bupropion hydrochloride er (sr) 2 QL(60/30)bupropion hydrochloride er (xl) tb24 150mg, 300mg

2 QL(30/30)

bupropion hydrochloride tabs 75mg

2 QL(180/30)

maprotiline hcl 4 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 4 QL(30/30)nefazodone hcl 4 QL(60/30)nefazodone hydrochloride 4 QL(60/30)SPRAVATO 56MG DOSE 5 PA NDSSPRAVATO 84MG DOSE 5 PA NDStrazodone hydrochloride tabs 100mg, 150mg, 50mg

1

trazodone hydrochloride tabs 300mg

2

TRINTELLIX 4 QL(30/30) STMonoamine Oxidase InhibitorsEMSAM 5 NDS QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 3tranylcypromine sulfate 4SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

4 QL(600/30)


1

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

promethegan 4scopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy Adjunctsaprepitant caps 40mg 4 B/D PA QL(1/30)aprepitant caps 125mg 4 B/D PA QL(2/28)aprepitant caps 80mg 4 B/D PA QL(4/28)aprepitant caps pack 4 B/D PA QL(6/28)dronabinol 4 PA QL(60/30)EMEND SUSR 4 B/D PA QL(6/28)granisetron hcl inj 1mg/ml 4 B/D PAgranisetron hcl tabs 4 B/D PA QL(30/30)granisetron hydrochloride 4 B/D PAondansetron hcl oral soln 4 B/D PA QL(450/30)ondansetron hcl tabs 2 B/D PA QL(15/30)ondansetron hydrochloride inj 4ondansetron hydrochloride tabs 2 B/D PA QL(90/30)ondansetron odt 2 B/D PA QL(90/30)sancuso 5 NDS QL(4/28)

Antifungals

AntifungalsABELCET 5 PA NDSAMBISOME 5 PA NDSamphotericin b 4 PAcaspofungin acetate 5 PA NDSciclodan 4ciclopirox nail lacquer 4ciclopirox olamine 4ciclopirox sham 4ciclopirox susp 4clotrimazole external crea 2clotrimazole external soln 3clotrimazole lozg 2clotrimazole/betamethasone dipropionate crea

2

clotrimazole/betamethasone dipropionate lotn

4

econazole nitrate 4fluconazole in nacl 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PAXIL SUSP 4 QL(900/30) STPRISTIQ 4 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 50mg 2 QL(120/30)sertraline hydrochloride tabs 100mg

2 QL(60/30)

venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg 2 QL(30/30)venlafaxine hcl er cp24 150mg 2 QL(60/30)venlafaxine hcl er cp24 75mg 2 QL(90/30)VIIBRYD 4 QL(30/30) STVIIBRYD STARTER PACK 4 QL(30/30) STTricyclicsamitriptyline hcl 2 PAamitriptyline hydrochloride tabs 10mg, 50mg

2 PA

amoxapine 4clomipramine hcl 4 PAdesipramine hcl 4imipramine hcl tabs 25mg, 50mg

2 PA

imipramine hydrochloride 2 PAnortriptyline hcl 2nortriptyline hydrochloride 2perphenazine/amitriptyline 4 PAprotriptyline hcl 4trimipramine maleate 4 PA

Antiemetics

Antiemetics, Othercompro 4meclizine hcl tabs 2phenadoz 4prochlorperazine 4promethazine hcl supp 4promethazine hcl syrp 2 PApromethazine hcl tabs 12.5mg 2 PApromethazine hydrochloride tabs 25mg, 50mg

2 PA

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

colchicine caps 3 QL(60/30)colchicine tabs 3 QL(120/30)febuxostat 3 QL(30/30) STMITIGARE 3 QL(60/30)probenecid 4probenecid/colchicine 4ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)dihydroergotamine mesylate nasal soln

4 PA QL(8/30)

ergotamine tartrate/caffeine 3 QL(40/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 4 QL(9/30)rizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 4 QL(12/30)sumatriptan 4 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

4 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

4 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

4 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

4 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3pyridostigmine bromide er 3pyridostigmine bromide tabs 60mg

3

REGONOL 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluconazole susr 4fluconazole tabs 2flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole caps 4 PA QL(120/30)itraconazole oral soln 5 PA NDSketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2naftifine hcl 4naftifine hydrochloride crea 4NATACYN 4NOXAFIL SUSP 5 PA NDS QL(600/30)NOXAFIL TBEC 5 PA NDS QL(96/30)nyamyc 4nystatin crea 2nystatin oint 2nystatin powd 3nystatin susp 2nystatin tabs 2nystatin/triamcinolone 4nystop 4POSACONAZOLE DR 5 PA NDS QL(96/30)SPORANOX ORAL SOLN 5 PA NDSterbinafine hcl tabs 1 QL(90/365)terconazole 4voriconazole inj 5 PA NDSvoriconazole susr 5 PA NDS QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 4

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MATULANE 5 NDSmelphalan hydrochloride 5 B/D PA NDSthiotepa 4 PATREANDA INJ 100MG 5 B/D PA NDSTREANDA INJ 25MG 5 B/D PA NDS

QL(8/21)VALCHLOR 5 PA NDS QL(60/30)YONDELIS 5 PA NDSZANOSAR 4 B/D PAAntiandrogensabiraterone acetate 5 PA NDS QL(120/30)bicalutamide 3 QL(30/30)ERLEADA 5 PA NDS QL(120/30)flutamide 4nilutamide 5 NDS QL(60/30)NUBEQA 5 PA NDS QL(120/30)XTANDI 5 PA NDS QL(120/30)YONSA 5 PA NDS QL(120/30)ZYTIGA TABS 500MG 5 PA NDS QL(60/30)ZYTIGA TABS 250MG 5 PA NDS QL(120/30)Antiangiogenic AgentsPOMALYST 5 PA NDS QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 PA NDS QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 PA NDS QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 PA NDS QL(28/28)

THALOMID CAPS 200MG 5 PA NDS QL(56/28)Antiestrogens/ModifiersEMCYT 4FARESTON 5 NDS QL(30/30)FASLODEX 5 B/D PA NDS

QL(30/30)fulvestrant 5 B/D PA NDS

QL(30/30)SOLTAMOX 5 NDStamoxifen citrate 2toremifene citrate 5 NDS QL(30/30)Antimetabolitesadrucil 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 4AntitubercularsCAPASTAT SULFATE 4cycloserine 2ethambutol hcl 4ethambutol hydrochloride 4isoniazid inj 4isoniazid syrp 4isoniazid tabs 2PASER 4PRIFTIN 4pyrazinamide 4rifampin 4RIFATER 4SIRTURO 4 PA QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA NDS

QL(8/21)BICNU 4 B/D PAbusulfan 5 B/D PA NDSBUSULFEX 5 B/D PA NDScarboplatin inj 450mg/45ml, 50mg/5ml

3 B/D PA

carmustine 4 B/D PAcyclophosphamide caps 4 B/D PAcyclophosphamide inj 5 B/D PA NDSdacarbazine 4 B/D PAEVOMELA 5 PA NDSGLEOSTINE 4ifosfamide inj 1gm, 3gm 4 B/D PAKISQALI FEMARA 200 DOSE 5 PA NDS QL(49/28)KISQALI FEMARA 400 DOSE 5 PA NDS QL(70/28)KISQALI FEMARA 600 DOSE 5 PA NDS QL(91/28)LEUKERAN 4

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XPOVIO 80 MG TWICE WEEKLY

5 PA NDS QL(32/28)

Antineoplastics, OtherABRAXANE 5 PA NDSADRIAMYCIN INJ 50MG 4 B/D PAadriamycin inj 2mg/ml 4 B/D PAarsenic trioxide 4 B/D PAazacitidine 5 B/D PA NDSBELEODAQ 5 PA NDSbleomycin 4 B/D PAbleomycin sulfate 4 B/D PABORTEZOMIB 5 PA NDS QL(14/21)BRAFTOVI 5 PA NDS QL(180/30)carboplatin inj 150mg/15ml 3 B/D PAcisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

4 B/D PA

COPIKTRA 5 PA NDS QL(60/30)dactinomycin 5 B/D PA NDSdaunorubicin hcl 4 B/D PADAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

4 B/D PA

daunorubicin hydrochloride inj 20mg/4ml

4 B/D PA

DAURISMO TABS 100MG 5 PA NDS QL(30/30)DAURISMO TABS 25MG 5 PA NDS QL(60/30)decitabine 5 NDSdexrazoxane 4 B/D PADOCETAXEL INJ 200MG/10ML 5 B/D PA NDSdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA NDS

doxorubicin hydrochloride liposomal

5 B/D PA NDS

doxorubicin hydrochloride liposome

5 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ALIMTA 5 PA NDSARRANON 4cladribine 4 B/D PAclofarabine 4 B/D PAcytarabine 4 B/D PAcytarabine aqueous 4 B/D PADROXIA 4ELITEK 5 B/D PA NDSfluorouracil inj 4 B/D PAFOLOTYN 5 B/D PA NDSgemcitabine 4 B/D PAgemcitabine hcl 4 B/D PAgemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml

4 B/D PA

gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

5 B/D PA NDS

hydroxyurea 2INFUGEM 5 B/D PA NDSLONSURF TABS 8.19MG; 20MG

5 PA NDS QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 PA NDS QL(100/28)

mercaptopurine 4NIPENT 5 B/D PA NDSPURIXAN 5 PA NDS QL(300/30)TABLOID 4VYXEOS 5 B/D PA NDSAntineoplasticsXPOVIO 100 MG ONCE WEEKLY

5 PA NDS QL(20/28)

XPOVIO 60 MG ONCE WEEKLY

5 PA NDS QL(12/28)

XPOVIO 80 MG ONCE WEEKLY

5 PA NDS QL(16/28)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ONCASPAR 5 B/D PA NDSoxaliplatin inj 100mg 5 B/D PA NDSoxaliplatin inj 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml

4 B/D PA

PIQRAY 200MG DAILY DOSE 5 PA NDS QL(28/28)PIQRAY 250MG DAILY DOSE 5 PA NDS QL(56/28)PIQRAY 300MG DAILY DOSE 5 PA NDS QL(56/28)PORTRAZZA 5 PA NDS QL(100/21)PROLEUKIN 5 B/D PA NDSromidepsin 5 PA NDSROZLYTREK CAPS 200MG 5 PA NDS QL(90/30)ROZLYTREK CAPS 100MG 5 PA NDS QL(150/30)RUBRACA 5 PA NDS QL(120/30)RYDAPT 5 PA NDS QL(224/28)SYLATRON 5 PA NDS QL(4/28)SYNRIBO 5 PA NDS QL(28/28)TALZENNA 5 PA NDS QL(90/30)TRISENOX 4 B/D PAVELCADE 5 PA NDS QL(14/21)VENCLEXTA STARTING PACK 5 PA NDS QL(84/365)VENCLEXTA TABS 50MG 4 PA QL(30/30)VENCLEXTA TABS 10MG 4 PA QL(60/30)VENCLEXTA TABS 100MG 5 PA NDS QL(120/30)VERZENIO 5 PA NDS QL(60/30)vinblastine sulfate 4 B/D PAvincristine sulfate 4 B/D PAvinorelbine tartrate inj 50mg/5ml

4 B/D PA

VITRAKVI CAPS 100MG 5 PA NDS QL(60/30)VITRAKVI CAPS 25MG 5 PA NDS QL(180/30)VITRAKVI ORAL SOLN 5 PA NDS QL(300/30)ZEJULA 5 PA NDS QL(90/30)ZOLINZA 5 NDS QL(120/30)ZYKADIA 5 PA NDS QL(140/28)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 4 QL(60/30)letrozole 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELZONRIS 5 PA NDSepirubicin hcl inj 200mg/100ml 4 B/D PAERWINAZE 5 B/D PA NDS

QL(60/28)ETHYOL 5 B/D PA NDSfludarabine phosphate inj 50mg 4 B/D PAFUSILEV 5 NDSHALAVEN 5 PA NDSidarubicin hcl inj 10mg/10ml 5 B/D PA NDSidarubicin hydrochloride inj 10mg/10ml

5 B/D PA NDS

INREBIC 5 PA NDS QL(120/30)irinotecan hcl 4 B/D PAirinotecan hydrochloride 4 B/D PAirinotecan inj 100mg/5ml, 500mg/25ml

4 B/D PA

ISTODAX (OVERFILL) 5 PA NDSJEVTANA 5 PA NDSKISQALI 5 PA NDS QL(63/28)LARTRUVO 5 PA NDSleucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg

4

leucovorin calcium tabs 10mg, 15mg, 25mg

4

leucovorin calcium tabs 5mg 3levoleucovorin 5 NDSlevoleucovorin calcium 5 NDSLORBRENA TABS 100MG 5 PA NDS QL(30/30)LORBRENA TABS 25MG 5 PA NDS QL(90/30)LYNPARZA 5 PA NDS QL(120/30)MEKTOVI 5 PA NDS QL(180/30)mesna 4 B/D PAMESNEX TABS 5 NDSmitomycin inj 40mg 5 B/D PA NDSmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 3 B/D PANERLYNX 5 PA NDS QL(180/30)NINLARO 5 PA NDS QL(3/28)ODOMZO 5 PA NDS QL(30/30)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMETRIQ 140MG DAILY DOSE KIT

5 PA NDS QL(112/28)

COTELLIC 5 PA NDS QL(63/28)ERIVEDGE 5 PA NDS QL(28/28)erlotinib hydrochloride tabs 100mg, 150mg

5 PA NDS QL(30/30)

erlotinib hydrochloride tabs 25mg

5 PA NDS QL(60/30)

FARYDAK 5 PA NDS QL(6/21)GILOTRIF 5 PA NDS QL(30/30)IBRANCE 5 PA NDS QL(21/28)ICLUSIG TABS 45MG 5 PA NDS QL(30/30)ICLUSIG TABS 15MG 5 PA NDS QL(60/30)IDHIFA 5 PA NDS QL(30/30)imatinib mesylate 5 PA NDS QL(60/30)IMBRUVICA CAPS 70MG 5 PA NDS QL(30/30)IMBRUVICA CAPS 140MG 5 PA NDS QL(120/30)IMBRUVICA TABS 5 PA NDS QL(30/30)INLYTA 5 PA NDS QL(120/30)IRESSA 5 PA NDS QL(30/30)JAKAFI 5 PA NDS QL(60/30)LENVIMA 10 MG DAILY DOSE 5 PA NDS QL(30/30)LENVIMA 12MG DAILY DOSE 5 PA NDS QL(90/30)LENVIMA 14 MG DAILY DOSE 5 PA NDS QL(60/30)LENVIMA 18 MG DAILY DOSE 5 PA NDS QL(90/30)LENVIMA 20 MG DAILY DOSE 5 PA NDS QL(60/30)LENVIMA 24 MG DAILY DOSE 5 PA NDS QL(90/30)LENVIMA 4 MG DAILY DOSE 5 PA NDS QL(30/30)LENVIMA 8 MG DAILY DOSE 5 PA NDS QL(60/30)MEKINIST TABS 2MG 5 PA NDS QL(30/30)MEKINIST TABS 0.5MG 5 PA NDS QL(90/30)NEXAVAR 5 PA NDS QL(120/30)SPRYCEL 5 PA NDS QL(30/30)STIVARGA 5 PA NDSSUTENT 5 PA NDS QL(28/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Enzyme InhibitorsBALVERSA TABS 5MG 5 PA NDS QL(30/30)BALVERSA TABS 4MG 5 PA NDS QL(60/30)BALVERSA TABS 3MG 5 PA NDS QL(90/30)etoposide inj 3 B/D PAirinotecan hydrochloride 4 B/D PAKYPROLIS 5 B/D PA NDStoposar 3 B/D PAtopotecan hcl inj 4mg 5 NDSMolecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 PA NDS QL(56/28)

AFINITOR DISPERZ TBSO 5MG

5 PA NDS QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 PA NDS QL(28/28)

AFINITOR TABS 10MG 5 PA NDS QL(56/28)ALECENSA 5 PA NDS QL(240/30)ALIQOPA 5 PA NDS QL(3/28)ALUNBRIG TABS 180MG, 90MG

5 PA NDS QL(30/30)

ALUNBRIG TABS 30MG 5 PA NDS QL(180/30)ALUNBRIG TBPK 5 PA NDS QL(60/365)BOSULIF TABS 400MG, 500MG

5 PA NDS QL(30/30)

BOSULIF TABS 100MG 5 PA NDS QL(120/30)CABOMETYX TABS 20MG, 60MG

5 PA NDS QL(30/30)

CABOMETYX TABS 40MG 5 PA NDS QL(60/30)CALQUENCE 5 PA NDS QL(60/30)CAPRELSA TABS 300MG 5 PA NDS QL(30/30)CAPRELSA TABS 100MG 5 PA NDS QL(60/30)COMETRIQ 100MG DAILY DOSE KIT

5 PA NDS QL(56/28)

COMETRIQ 60MG DAILY DOSE KIT

5 PA NDS QL(84/28)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PERJETA 5 PA NDSPOTELIGEO 5 PA NDSRITUXAN 5 PA NDSRITUXAN HYCELA 5 PA NDSTECENTRIQ INJ 1200MG/20ML

5 PA NDS QL(20/21)

TECENTRIQ INJ 840MG/14ML 5 PA NDS QL(28/28)UNITUXIN 5 PA NDSVECTIBIX 5 PA NDSYERVOY INJ 50MG/10ML 5 PA NDSYERVOY INJ 200MG/40ML 5 PA NDS QL(80/21)Retinoidsbexarotene 5 NDSPANRETIN 5 NDSTARGRETIN GEL 5 NDS QL(60/30)tretinoin caps 5 NDS

Antiparasitics

Anthelminticsalbendazole 5 NDSALBENZA 5 NDSBILTRICIDE 4ivermectin tabs 3praziquantel 4AntiprotozoalsALINIA SUSR 5 NDS QL(150/30)ALINIA TABS 5 NDS QL(20/30)atovaquone 4atovaquone/proguanil hcl 4chloroquine phosphate 2COARTEM 4 QL(24/30)DARAPRIM 5 NDS QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 3 B/D PA QL(6/28)PENTAM 300 3pentamidine isethionate 3PRIMAQUINE PHOSPHATE 4quinine sulfate 4 QL(42/7)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TAFINLAR 5 PA NDS QL(120/30)TAGRISSO 5 PA NDS QL(30/30)TARCEVA TABS 100MG, 150MG

5 PA NDS QL(30/30)

TARCEVA TABS 25MG 5 PA NDS QL(60/30)TASIGNA CAPS 150MG, 200MG

5 PA NDS QL(112/28)

TASIGNA CAPS 50MG 5 PA NDS QL(420/30)temsirolimus 5 B/D PA NDS

QL(4/28)TIBSOVO 5 PA NDS QL(60/30)TURALIO 5 PA NDS QL(120/30)TYKERB 5 PA NDS QL(180/30)VIZIMPRO 5 PA NDS QL(30/30)VOTRIENT 5 PA NDS QL(120/30)XALKORI 5 PA NDS QL(60/30)XOSPATA 5 PA NDS QL(90/30)ZALTRAP 5 PA NDS QL(40/28)ZELBORAF 5 PA NDS QL(240/30)ZYDELIG 5 PA NDS QL(60/30)ZYKADIA 5 PA NDS QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 5 PA NDSBAVENCIO 5 PA NDSBESPONSA 5 PA NDSCYRAMZA 5 PA NDSDARZALEX 5 PA NDSEMPLICITI 5 PA NDSERBITUX 5 PA NDSGAZYVA 5 PA NDSHERCEPTIN HYLECTA 5 PA NDSIMFINZI 5 PA NDSKADCYLA 5 PA NDSKANJINTI INJ 420MG 5 PA NDSKEYTRUDA 5 PA NDSLIBTAYO 5 PA NDS QL(7/21)LUMOXITI 5 PA NDSMVASI 5 PA NDSMYLOTARG 5 PA NDSOPDIVO 5 PA NDS QL(80/28)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Monoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 4 QL(30/30)selegiline hcl 3

Antipsychotics

1st Generation/Typicalchlorpromazine hcl 4fluphenazine decanoate 4fluphenazine hcl conc 4fluphenazine hcl inj 4fluphenazine hcl tabs 2fluphenazine hydrochloride 4haloperidol 2haloperidol decanoate 4haloperidol lactate 4loxapine 4loxapine succinate 4molindone hydrochloride 2perphenazine 4pimozide 4prochlorperazine edisylate inj 10mg/2ml

4

prochlorperazine maleate 2thioridazine hcl 4thiothixene 4trifluoperazine hcl 42nd Generation/AtypicalABILIFY MAINTENA 5 NDS QL(1/28)aripiprazole odt 5 NDS QL(60/30)aripiprazole oral soln 4 QL(900/30)aripiprazole tabs 4 QL(30/30)ARISTADA INITIO 5 NDS QL(4.8/365)ARISTADA INJ 441MG/1.6ML 5 NDS QL(1.6/28)ARISTADA INJ 662MG/2.4ML 5 NDS QL(2.4/28)ARISTADA INJ 882MG/3.2ML 5 NDS QL(3.2/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Pediculicides/Scabicideslindane 4malathion 4permethrin 3

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAtrihexyphenidyl hydrochloride 2 PAAntiparkinson Agents, Otheramantadine hcl 3entacapone 4 QL(240/30)Dopamine AgonistsAPOKYN 5 PA NDS QL(60/30)bromocriptine mesylate 4NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

4 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

4 QL(90/30)

ropinirole hcl 2ropinirole hydrochloride tabs 0.25mg, 3mg

2

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa/levodopa 2carbidopa/levodopa er 4carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

4

RYTARY 4 ST

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REXULTI 5 NDS QL(30/30)RISPERDAL CONSTA INJ 50MG

5 NDS QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

4 QL(60/30)

risperidone odt tbdp 4mg 4 QL(120/30)risperidone oral soln 4 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30)VRAYLAR CAPS 5 NDS QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 4 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 NDS QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 NDS QL(2/28)

Treatment-Resistantclozapine odt tbdp 200mg 5 NDS QL(120/30)clozapine odt tbdp 12.5mg, 25mg

4

clozapine odt tbdp 150mg 4 QL(180/30)clozapine odt tbdp 100mg 4 QL(270/30)clozapine tabs 200mg 4 QL(120/30)clozapine tabs 100mg 4 QL(270/30)clozapine tabs 25mg, 50mg 3VERSACLOZ 4 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 2dantrolene sodium caps 4tizanidine hcl tabs 2tizanidine hydrochloride tabs 4mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/56)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 NDS QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

5 NDS QL(0.5/28)


5 NDS QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 NDS QL(1/28)


5 NDS QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

4 QL(30/30)

LATUDA TABS 80MG 4 QL(60/30)NUPLAZID 5 PA NDS QL(30/30)olanzapine inj 4 QL(30/30)olanzapine odt 4 QL(30/30)olanzapine tabs 2 QL(30/30)paliperidone er tb24 1.5mg, 3mg, 9mg

4 QL(30/30) ST

paliperidone er tb24 6mg 4 QL(60/30) STPERSERIS 5 NDS QL(1/30)quetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

4 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

4 QL(60/30)

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ISENTRESS CHEW 25MG 3 QL(180/30)ISENTRESS HD 5 NDS QL(60/30)ISENTRESS PACK 5 NDS QL(180/30)ISENTRESS TABS 5 NDS QL(60/30)JULUCA 5 NDS QL(30/30)TIVICAY TABS 25MG, 50MG 5 NDS QL(60/30)TIVICAY TABS 10MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 NDS QL(30/30)EDURANT 5 NDS QL(30/30)efavirenz caps 200mg 3 QL(60/30)efavirenz caps 50mg 3 QL(90/30)efavirenz tabs 5 NDS QL(30/30)INTELENCE TABS 100MG, 200MG

5 NDS QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 4 QL(30/30)nevirapine er tb24 100mg 4 QL(90/30)nevirapine susp 4 QL(1200/30)nevirapine tabs 4 QL(60/30)ODEFSEY 5 NDS QL(30/30)PIFELTRO 5 NDS QL(30/30)RESCRIPTOR 4 QL(180/30)STRIBILD 5 NDS QL(30/30)SYMFI 5 NDS QL(30/30)SYMFI LO 5 NDS QL(30/30)VIRAMUNE SUSP 4 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 3 QL(960/30)abacavir sulfate/lamivudine 5 NDS QL(30/30)abacavir sulfate/lamivudine/zidovudine

5 NDS QL(60/30)

abacavir tabs 4 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5 NDSganciclovir inj 500mg, 500mg/10ml

3 B/D PA

valganciclovir 5 NDSvalganciclovir hydrochlorde 5 NDSZIRGAN 3Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 5 NDS QL(30/30)BARACLUDE ORAL SOLN 4 QL(630/30)entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 3INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU

5 NDS

INTRON A INJ 6000000UNIT/ML

4

lamivudine tabs 100mg 3Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 3 PA QL(28/28)HARVONI 3 QL(28/28)VOSEVI 5 PA NDS QL(30/30)Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 5 PA NDS QL(2/28)PEGASYS INJ 180MCG/ML 5 PA NDS QL(4/28)PEGASYS PROCLICK 5 PA NDS QL(2/28)ribavirin caps 3 QL(168/28)ribavirin tabs 3 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 NDS QL(30/30)DELSTRIGO 5 NDS QL(30/30)DOVATO 5 NDS QL(30/30)GENVOYA 5 NDS QL(30/30)ISENTRESS CHEW 100MG 5 NDS QL(180/30)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CRIXIVAN CAPS 400MG 4 QL(180/30)CRIXIVAN CAPS 200MG 4 QL(270/30)EVOTAZ 5 NDS QL(30/30)fosamprenavir calcium 5 NDS QL(120/30)INVIRASE 5 NDS QL(120/30)KALETRA TABS 200MG; 50MG

5 NDS QL(120/30)

KALETRA TABS 100MG; 25MG

4 QL(300/30)

LEXIVA SUSP 4 QL(1575/28)lopinavir/ritonavir 4 QL(480/30)NORVIR ORAL SOLN 3 QL(480/30)NORVIR PACK 4 QL(360/30)PREZCOBIX 5 NDS QL(30/30)PREZISTA SUSP 5 NDS QL(400/30)PREZISTA TABS 800MG 5 NDS QL(30/30)PREZISTA TABS 600MG 5 NDS QL(60/30)PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 4 QL(210/30)REYATAZ PACK 5 NDS QL(180/30)ritonavir 3 QL(360/30)SYMTUZA 5 NDS QL(30/30)VIRACEPT TABS 625MG 5 NDS QL(120/30)VIRACEPT TABS 250MG 5 NDS QL(270/30)Anti-influenzaAgentsoseltamivir phosphate caps 3oseltamivir phosphate susr 4rimantadine hcl 2Antiherpetic Agentsacyclovir caps 2acyclovir oint 4 QL(30/30)acyclovir sodium 4 B/D PAacyclovir susp 4acyclovir tabs 2famciclovir 4 QL(60/30)trifluridine 4valacyclovir hcl 3 QL(30/30)valacyclovir hydrochloride 3 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CIMDUO 5 NDS QL(30/30)DESCOVY 5 NDS QL(30/30)didanosine 4 QL(30/30)EMTRIVA CAPS 3 QL(30/30)EMTRIVA ORAL SOLN 3 QL(680/28)lamivudine oral soln 3 QL(900/30)lamivudine tabs 300mg 3 QL(30/30)lamivudine tabs 150mg 3 QL(60/30)lamivudine/zidovudine 4 QL(60/30)RETROVIR IV INFUSION 4stavudine caps 30mg, 40mg 4 QL(60/30)stavudine caps 15mg, 20mg 3 QL(60/30)tenofovir disoproxil fumarate 5 NDS QL(30/30)TRIUMEQ 5 NDS QL(30/30)TRUVADA 5 NDS QL(30/30)VIDEX EC CPDR 125MG 4VIDEX PEDIATRIC 4 QL(1200/30)VIREAD POWD 5 NDS QL(240/30)VIREAD TABS 150MG, 200MG, 250MG

5 NDS QL(30/30)

zidovudine caps 4 QL(180/30)zidovudine syrp 4 QL(1680/28)zidovudine tabs 4 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 NDS QL(30/30)FUZEON 5 NDS QL(60/30)SELZENTRY ORAL SOLN 5 NDS QL(1610/26)SELZENTRY TABS 150MG, 75MG

5 NDS QL(60/30)

SELZENTRY TABS 300MG 5 NDS QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)TROGARZO 5 B/D PA NDSTYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 NDS QL(120/30)APTIVUS ORAL SOLN 5 NDS QL(285/28)atazanavir sulfate caps 300mg 5 NDS QL(30/30)atazanavir sulfate caps 200mg 5 NDS QL(60/30)atazanavir sulfate caps 150mg 4 QL(30/30)

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2 QL(90/30)BYDUREON BCISE 4 QL(4/28)BYDUREON PEN 4 QL(4/28)BYETTA INJ 5MCG/0.02ML 4 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 4 QL(2.4/30)CYCLOSET 4 QL(180/30)FARXIGA 3 QL(30/30)FORTAMET 4 QL(60/30) STglimepiride tabs 4mg 1 QL(60/30)glimepiride tabs 2mg 1 QL(120/30)glimepiride tabs 1mg 1 QL(240/30)glipizide er tb24 10mg 2 QL(60/30)glipizide er tb24 5mg 2 QL(120/30)glipizide er tb24 2.5mg 2 QL(240/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 2 QL(60/30)glipizide xl tb24 5mg 2 QL(120/30)glipizide xl tb24 2.5mg 2 QL(240/30)glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hydrochloride tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 3 QL(30/30)INVOKAMET 4 QL(60/30)INVOKAMET XR 4 QL(60/30)INVOKANA 4 QL(30/30)JANUMET 3 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

3 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anxiolytics

Anxiolytics, Otherbuspirone hcl 2buspirone hydrochloride tabs 10mg, 5mg, 7.5mg

2

doxepin hcl 4 PAdoxepin hydrochloride caps 25mg

4 PA

Benzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

3 QL(90/30)

alprazolam odt tbdp 2mg 3 QL(150/30)alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam inj 5mg/ml 2diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 4 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 4lorazepam intensol 4 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium carbonate caps 300mg 1lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2lithium carbonate tabs 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

3 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

3 QL(60/30)

Glycemic AgentsBAQSIMI ONE PACK 3 QL(2/30)BAQSIMI TWO PACK 3 QL(2/30)GLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 6HUMALOG JUNIOR KWIKPEN 6HUMALOG KWIKPEN 6HUMALOG MIX 50/50 6HUMALOG MIX 50/50 KWIKPEN

6

HUMALOG MIX 75/25 6HUMALOG MIX 75/25 KWIKPEN

6

HUMULIN 70/30 6HUMULIN 70/30 KWIKPEN 6HUMULIN N 6HUMULIN N KWIKPEN 6HUMULIN R 6HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 6LANTUS 6LANTUS SOLOSTAR 6LEVEMIR 6LEVEMIR FLEXTOUCH 6SOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 6TOUJEO SOLOSTAR 6TRESIBA 6

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JANUMET XR TB24 1000MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JARDIANCE 3 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

metformin hcl er tb24 750mg (generic for Glucophage XR)

1 QL(60/30)

metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hcl er tb24 1000mg (generic for Glumetza)

4 QL(60/30) ST

metformin hcl er tb24 500mg (generic for Glumetza)

4 QL(120/30) ST

metformin hcl er tb24 1000mg, 500mg (generic for Fortamet)

4 QL(60/30)

metformin hydrochloride oral soln

4 QL(750/30)

metformin hydrochloride tabs 1000mg

1 QL(60/30)


1 QL(90/30)


1 QL(150/30)

nateglinide 2 QL(90/30)OZEMPIC 3 QL(3/28)pioglitazone hcl 1 QL(30/30)pioglitazone hcl/metformin hcl 2 QL(90/30)pioglitazone hydrochloride tabs 15mg, 30mg

1 QL(30/30)

repaglinide tabs 0.5mg, 1mg 4 QL(120/30)repaglinide tabs 2mg 4 QL(240/30)RIOMET 4 QL(750/30)SYMLINPEN 120 4 PA QL(10.8/28)SYMLINPEN 60 4 PA QL(6/30)SYNJARDY 3 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

3 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

3 QL(60/30)

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PRADAXA 4 QL(60/30)warfarin sodium 1XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 10MG, 20MG 3 QL(30/30)XARELTO TABS 15MG, 2.5MG 3 QL(60/30)BloodFormationModifiersanagrelide hydrochloride 3ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA NDS QL(1/21)

ARANESP ALBUMIN FREE INJ 150MCG/0.3ML

5 PA NDS QL(1.2/28)


5 PA NDS QL(1.6/28)


5 PA NDS QL(2/28)


5 PA NDS QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA NDS QL(4/28)


4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)


4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

MOZOBIL 5 NDS QL(9.6/30)PROCRIT INJ 40000UNIT/ML 5 PA NDS QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA NDS QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

PROMACTA PACK 5 PA NDS QL(360/30)PROMACTA TABS 5 PA NDS QL(30/30)ZARXIO 5 PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRESIBA FLEXTOUCH 6XULTOPHY 100/3.6 3 QL(15/30) ST

BloodProducts/Modifiers/VolumeExpanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 4 QL(74/30)ELIQUIS TABS 2.5MG 4 QL(60/30)ELIQUIS TABS 5MG 4 QL(74/30)enoxaparin sodium 4fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux sodium inj 5mg/0.4ml

5 NDS QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 NDS QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

5 NDS QL(24/90)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml

3

heparin sodium inj 5000unit/0.5ml

4

heparin sodium/d5w 4heparin sodium/dextrose 4heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45%

4

heparin sodium/nacl 0.9% 4heparin sodium/sodium chloride 0.9%

4

heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9%

4

heparin sodium/sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45%

4

jantoven 1

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

candesartan cilexetil/hydrochlorothiazide

2

EDARBI 4 QL(30/30) STEDARBYCLOR 4 STENTRESTO 3 QL(60/30)irbesartan tabs 300mg 1 QL(30/30)irbesartan tabs 150mg, 75mg 1 QL(60/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium 1 QL(60/30)losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 2olmesartan medoxomil/hydrochlorothiazide

4

telmisartan tabs 20mg, 40mg 2 QL(30/30)telmisartan tabs 80mg 2 QL(60/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg

2 QL(30/30)

telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg

2 QL(60/30)

valsartan tabs 320mg 2 QL(30/30)valsartan tabs 160mg, 40mg, 80mg

2 QL(60/30)

valsartan/hydrochlorothiazide 2 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 QL(60/30)benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg

2 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

2 QL(60/30)

benazepril hydrochloride 1 QL(60/30)captopril 4captopril/hydrochlorothiazide 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hemostasis AgentsRETACRIT INJ 40000UNIT/ML 5 PA NDS QL(6/28)RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

tranexamic acid inj 2tranexamic acid tabs 3 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 4 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)dipyridamole tabs 2 PAprasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

3 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 3 QL(8/28)clonidine hcl tabs 0.3mg 2clonidine hcl tabs 0.1mg 1clonidine hydrochloride tabs 1midodrine hcl 2Alpha-adrenergic Blocking Agentsdoxazosin mesylate tabs 1mg, 2mg, 4mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)phenoxybenzamine hydrochloride

5 NDS

prazosin hcl 4prazosin hydrochloride caps 2mg

4

terazosin hcl caps 1mg, 5mg 1terazosin hcl caps 10mg 1 QL(60/30)terazosin hydrochloride 1Angiotensin II Receptor Antagonistscandesartan cilexetil tabs 32mg 2 QL(30/30)candesartan cilexetil tabs 16mg, 4mg, 8mg

2 QL(60/30)

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MULTAQ 3 QL(60/30)pacerone 4propafenone hcl 4propafenone hydrochloride er 4quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2sotalol hcl af 2sotalol hydrochloride (af) tabs 80mg

2

sotalol hydrochloride af 2sotalol hydrochloride tabs 120mg, 80mg

2

Beta-adrenergic Blocking Agentsacebutolol hcl caps 200mg 2acebutolol hydrochloride caps 400mg

2

atenolol 1atenolol/chlorthalidone 1betaxolol hcl tabs 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

4 QL(30/30)

BYSTOLIC TABS 20MG 4 QL(60/30)carvedilol 1carvedilol phosphate 4 QL(30/30)labetalol hydrochloride inj 5mg/ml

4

labetalol hydrochloride tabs 4metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 4metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide

1

fosinopril sodium 2 QL(60/30)fosinopril sodium/hydrochlorothiazide

2 QL(120/30)

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 2perindopril erbumine 2 QL(60/30)quinapril hcl 1 QL(60/30)quinapril hydrochloride tabs 10mg

1 QL(60/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

2 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

2 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 2 QL(30/30)trandolapril tabs 2mg, 4mg 2 QL(60/30)Antiarrhythmicsamiodarone hcl inj 50mg/ml, 900mg/18ml

4

amiodarone hcl tabs 400mg 4amiodarone hcl tabs 100mg, 200mg

2

amiodarone hydrochloride inj 4dofetilide 4 QL(60/30)flecainide acetate 4lidocaine hcl inj 100mg/5ml, 50mg/5ml

4

mexiletine hcl 4

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

felodipine er 2 QL(60/30)isradipine 4matzim la 2nicardipine hcl 4nifedipine er tb24 90mg 2 QL(30/30)nifedipine er tb24 30mg, 60mg 2 QL(60/30)nimodipine 4taztia xt cp24 120mg, 180mg, 240mg, 300mg

2

verapamil hcl 1verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2VERAPAMIL HCL SR CP24 360MG

3 QL(30/30)

verapamil hydrochloride inj 4verapamil hydrochloride tabs 1Cardiovascular Agents, Otheraliskiren 3 QL(30/30)atropine sulfate inj 0.5mg/5ml 4CORLANOR TABS 4 PA QL(60/30)DEMSER 5 NDSdigitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 4 PAdigox tabs 250mcg 4 PAdigox tabs 125mcg 2 QL(30/30)digoxin inj 4 PAdigoxin tabs 250mcg 4 PAdigoxin tabs 125mcg 2 QL(30/30)NORTHERA CAPS 100MG 5 PA NDS QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA NDS QL(180/30)

pentoxifylline er 2RANEXA 3 QL(60/30)ranolazine er 3 QL(60/30)TEKTURNA 3 QL(30/30)TEKTURNA HCT 3 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nadolol 4nadolol/bendroflumethiazide 4pindolol 2propranolol hcl er 4propranolol hcl inj 4propranolol hcl oral soln 2propranolol hcl tabs 40mg, 80mg

2

propranolol hydrochloride er 4propranolol hydrochloride tabs 10mg, 20mg, 60mg

2

propranolol/hydrochlorothiazide 3timolol maleate tabs 4Calcium Channel Blocking Agentsamlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hcl caps 5mg; 40mg

2 QL(60/30)

amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg

2 QL(30/30)

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg

2 QL(60/30)

amlodipine besylate/valsartan 2amlodipine/valsartan/hctz 2amlodipine/valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg

2

cartia xt 2dilt-xr 2diltiazem cd cp24 180mg 2diltiazem hcl er cp12 2diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg

2

diltiazem hcl er tb24 2diltiazem hcl inj 4diltiazem hcl tabs 2diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg

2

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fenofibrate tabs 48mg, 54mg 4 QL(60/30)fenofibric acid dr cpdr 135mg 4 QL(30/30)fenofibric acid dr cpdr 45mg 4 QL(60/30)gemfibrozil 2 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)LIVALO 3 QL(30/30) STlovastatin tabs 10mg, 20mg 1 QL(30/30)lovastatin tabs 40mg 1 QL(60/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 2 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 4cholestyramine light 4colestipol hcl 4ezetimibe 3 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacin tabs 500mg 2niacor 2NIASPAN TBCR 500MG 4 QL(30/30) STNIASPAN TBCR 1000MG, 750MG

4 QL(60/30) ST

omega-3-acid ethyl esters 4 QL(120/30)PRALUENT 5 PA NDSprevalite 4REPATHA 5 PA NDSREPATHA PUSHTRONEX SYSTEM

5 PA NDS

REPATHA SURECLICK 5 PA NDSVASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)VYTORIN 4 QL(30/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acetazolamide sodium 4methazolamide 4Diuretics, Loopbumetanide inj 4bumetanide tabs 2mg 3bumetanide tabs 0.5mg, 1mg 2ethacrynate sodium 4furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 1spironolactone 2spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 2hydrochlorothiazide 1indapamide 1metolazone 3Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 134mg, 200mg 3 QL(30/30)fenofibrate caps 67mg 3 QL(60/30)fenofibrate caps 130mg, 150mg 4 QL(30/30)fenofibrate caps 43mg, 50mg 4 QL(60/30)fenofibrate micronized caps 134mg, 200mg

3 QL(30/30)

fenofibrate micronized caps 67mg

3 QL(60/30)

fenofibrate tabs 145mg, 160mg 4 QL(30/30)

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

4 QL(60/30)


4 QL(90/30)


4 QL(120/30)

dextroamphetamine sulfate oral soln

4 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

4 QL(60/30)

dextroamphetamine sulfate tabs 10mg

4 QL(180/30)

AttentionDeficitHyperactivityDisorderAgents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

4 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

4 QL(60/30)

clonidine hcl er 4 QL(120/30)dexmethylphenidate hcl tabs 10mg

2 QL(60/30)

dexmethylphenidate hydrochloride tabs 2.5mg, 5mg

2 QL(60/30)

metadate er 4 QL(90/30)methylphenidate hydrochloride er tb24 27mg, 54mg

4 QL(30/30)

methylphenidate hydrochloride er tb24 36mg

4 QL(60/30)

methylphenidate hydrochloride er tb24 18mg

4 QL(120/30)

methylphenidate hydrochloride er tbcr 10mg

4 QL(30/30)


4 QL(60/30)


4 QL(90/30)

methylphenidate hydrochloride tabs

4 QL(90/30)

Central Nervous System, OtherHETLIOZ 5 PA NDS QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

WELCHOL 3ZETIA 4 QL(30/30) STVasodilators, Direct-acting Arterialhydralazine hcl inj 4hydralazine hcl tabs 2hydralazine hydrochloride tabs 100mg, 25mg, 50mg

2

minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 3 QL(180/30)isosorbide dinitrate er 3isosorbide dinitrate tabs 4isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)nitroglycerin inj 4nitroglycerin lingual 4nitroglycerin subl 2nitroglycerin transdermal 2 QL(30/30)

Central Nervous System Agents

AttentionDeficitHyperactivityDisorderAgents,Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

4 QL(30/30)

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg

4 QL(60/30)

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

2 QL(60/30)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pilocarpine hydrochloride tabs 5mg

4

triamcinolone acetonide dental paste

4

Dermatological Agents

Dermatological Agentsacitretin 4 PAammonium lactate 2amnesteem 4avita crea 4 PA QL(45/30)avita gel 4 PAcalcipotriene crea 4 QL(120/30)calcipotriene external soln 4 QL(60/30)calcipotriene oint 4 QL(120/30)calcitrene 4 QL(120/30)calcitriol oint 3 QL(800/30)claravis 4CURITY GAUZE PADS 2”X2” 6diclofenac sodium gel 1% 3 QL(1000/30)diclofenac sodium transdermal soln

4 QL(1050/30)

ELIDEL 4 QL(100/90)erythromycin/benzoyl peroxide 4fluorouracil crea 5% 4fluorouracil crea 0.5% 5 NDSfluorouracil external soln 4imiquimod 4 QL(12/30)isotretinoin 4methoxsalen 4myorisan 4PICATO GEL 0.05% 4 QL(2/56)PICATO GEL 0.015% 4 QL(3/56)pimecrolimus 4 QL(100/90)podofilox 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYRICA CR TB24 330MG 3 QL(60/30)LYRICA CR TB24 165MG, 82.5MG

3 QL(90/30)

NAMZARIC C4PK 4 PA QL(56/365)NAMZARIC CP24 4 PA QL(30/30)NUEDEXTA 4 PA QL(60/30)riluzole 4tetrabenazine tabs 12.5mg 5 PA NDS QL(90/30)tetrabenazine tabs 25mg 5 PA NDS QL(120/30)Multiple Sclerosis AgentsAMPYRA 5 PA NDS QL(60/30)AVONEX 5 PA NDS QL(4/28)AVONEX PEN 5 PA NDS QL(4/28)BETASERON 5 PA NDS QL(14/28)COPAXONE INJ 40MG/ML 5 PA NDS QL(12/28)COPAXONE INJ 20MG/ML 5 PA NDS QL(30/30)dalfampridine er 4 PA QL(60/30)GILENYA 5 PA NDS QL(30/30)REBIF 5 PA NDS QL(6/28)REBIF REBIDOSE 5 PA NDS QL(6/28)REBIF REBIDOSE TITRATION PACK

5 PA NDS QL(4.2/28)

REBIF TITRATION PACK 5 PA NDS QL(4.2/28)TECFIDERA CPDR 120MG 5 PA NDS QL(14/30)TECFIDERA CPDR 240MG 5 PA NDS QL(60/30)TECFIDERA STARTER PACK 5 PA NDS

QL(120/365)TYSABRI 5 PA NDS QL(15/28)

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 4paroex 1pilocarpine hcl 4

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 10%/nacl 0.2% 4 B/D PAdextrose 2.5%/nacl 0.45% 4 B/D PADEXTROSE 20% 4 B/D PADEXTROSE 25% 4 B/D PADEXTROSE 30% 4 B/D PADEXTROSE 40% 4 B/D PADEXTROSE 5% 4dextrose 5%/lactated ringers 4 B/D PAdextrose 5%/nacl 0.2% 4dextrose 5%/nacl 0.225% 4DEXTROSE 5%/NACL 0.3% 4dextrose 5%/nacl 0.33% 4dextrose 5%/nacl 0.45% 4dextrose 5%/nacl 0.9% 4DEXTROSE 50% 4 B/D PADEXTROSE 70% 4fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 4 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

HEPATAMINE 4 B/D PAKABIVEN 4 B/D PAKCL 0.075%/D5W/NACL 0.45% 4 B/D PAKCL 0.15%/D5W/NACL 0.2% 4 B/D PAKCL 0.15%/D5W/NACL 0.225% 4 B/D PAKCL 0.15%/D5W/NACL 0.45% 4 B/D PAKCL 0.15%/D5W/NACL 0.9% 4 B/D PAKCL 0.3%/D5W/NACL 0.45% 4 B/D PAKCL 0.3%/D5W/NACL 0.9% 4 B/D PAklor-con 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RECTIV 4 QL(30/30)REGRANEX 5 PA NDS QL(15/30)SANTYL 3selenium sulfide lotn 2tacrolimus oint 4 QL(100/90)tazarotene 4TAZORAC CREA 4TAZORAC GEL 4 QL(100/30)TOLAK 4tretinoin crea 4 PA QL(45/30)tretinoin gel 0.025% 4 PAtretinoin gel 0.05% 4 PA QL(45/30)tretinoin gel 0.01% 3 PA QL(45/30)tretinoin microsphere 4 PAtretinoin microsphere pump gel 0.1%

4 PA

zenatane 4

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN II 4 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 4 B/D PACARBAGLU 5 PA NDSCLINIMIX 4.25%/DEXTROSE 10%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 25%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 5%

4 B/D PA

CLINIMIX 5%/DEXTROSE 15% 4 B/D PACLINIMIX 5%/DEXTROSE 20% 4 B/D PACLINIMIX 5%/DEXTROSE 25% 4 B/D PACLINIMIX E 4.25%/DEXTROSE 10%

4 B/D PA

CLINISOL SF 15% 4 B/D PAdextrose 4 B/D PAdextrose10%/nacl 0.45% 4 B/D PAdextrose5% /electrolyte #48 viaflex

4 B/D PA

DEXTROSE 10% 4 B/D PA

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L

4 B/D PA

potassium chloride/dextrose/lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

4 B/D PA

potassium chloride/dextrose/sodium chloride

4 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

4 B/D PA

potassium citrate er 4PREMASOL 4 B/D PAPROCALAMINE 4 B/D PAPROSOL 4 B/D PAringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l

4 B/D PA

sodium bicarbonate inj 4sodium chloride 0.45% 4sodium chloride inj 0.45%, 0.9%, 3%, 5%

4

sodium fluoride chew 0.25mg, 0.5mg, 1mg

1

SODIUM LACTATE INJ 5MEQ/ML

4 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE 4 B/D PAElectrolyte/Mineral/MetalModifiersCHEMET 5 NDSCUPRIMINE 5 NDSDEPEN TITRATABS 5 NDSEXJADE 5 NDS STFERRIPROX 5 PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KLOR-CON 10 3KLOR-CON 8 3klor-con m10 1klor-con m20 1klor-con sprinkle 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

4 B/D PA

LACTATED RINGERS VIAFLEX

4 B/D PA

ludent 1MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML

4 B/D PA

magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50%

4 B/D PA

NEPHRAMINE 4 B/D PANORMOSOL -R 4 B/D PANORMOSOL-M IN D5W 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN D5W 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PApotassium chloride cr 1potassium chloride er cpcr 2potassium chloride er tbcr 1potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride oral soln 4potassium chloride pack 2potassium chloride sr 1potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l

4 B/D PA

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hyoscyamine sulfate elix 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 4nulev 2oscimin 2propantheline bromide 4Gastrointestinal Agents, Othercromolyn sodium conc 4diphenoxylate/atropine 4GATTEX 5 PA NDSloperamide hcl caps 2metoclopramide hcl inj 4metoclopramide hcl oral soln 2metoclopramide hcl tabs 2metoclopramide hydrochloride 2OSMOPREP 4RELISTOR INJ 8MG/0.4ML 5 PA NDS

QL(11.2/28)RELISTOR INJ 12MG/0.6ML 5 PA NDS

QL(16.8/28)TRULANCE 4 QL(30/30)ursodiol 3Histamine2 (H2) Receptor Antagonistsfamotidine inj 4famotidine premixed 4famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl inj 4ranitidine hcl syrp 4ranitidine hcl tabs 150mg, 300mg

1

ranitidine hydrochloride caps 4ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml

4

Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 1mg

5 PA NDS QL(60/30)

alosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JADENU 5 NDSJADENU SPRINKLE 5 NDSkionex 3penicillamine 5 NDSSAMSCA TABS 15MG 5 PA NDS QL(30/30)SAMSCA TABS 30MG 5 PA NDS QL(60/30)sodium polystyrene sulfonate powd

3

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

3

sps 3SYPRINE 5 NDStrientine hydrochloride 5 NDSVELTASSA 3Phosphate BindersAURYXIA 4 PA QL(360/30)calcium acetate caps 3calcium acetate tabs 667mg 3PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)sevelamer carbonate pack 4 QL(180/30)sevelamer carbonate tabs 4 QL(540/30)VELPHORO 4 QL(180/30)Vitaminsmultivitamin with fluoride chew 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml

4

dicyclomine hcl oral soln 4dicyclomine hydrochloride caps 2dicyclomine hydrochloride tabs 2ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 1mg, 2mg 4

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CREON 3CYSTADANE 5 NDSCYSTAGON 4ELAPRASE 5 PA NDSFABRAZYME 5 B/D PA NDSKUVAN 5 PA NDSLUMIZYME 5 PA NDSmiglustat 5 NDS QL(90/30)NAGLAZYME 5 PA NDSNITISINONE CAPS 2MG 5 NDSnitisinone caps 10mg, 5mg 5 NDSORFADIN 5 NDSsodium phenylbutyrate 5 PA NDSZENPEP 3

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 4 QL(30/30)flavoxate hcl 3MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 5mg

2 QL(30/30)

oxybutynin chloride er tb24 10mg, 15mg

2 QL(60/30)

oxybutynin chloride syrp 2 QL(600/30)oxybutynin chloride tabs 2 QL(120/30)solifenacin succinate 3 QL(30/30)tolterodine tartrate 4 QL(60/30)tolterodine tartrate er 4 QL(30/30)VESICARE 4 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

4 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AMITIZA 3 QL(60/30)LINZESS 3 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2lactulose oral soln 2MOVIPREP 4peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 3sucralfate 2Proton Pump InhibitorsDEXILANT 4 QL(60/30) STesomeprazole magnesium 4 QL(60/30)omeprazole cpdr 2 QL(60/30)pantoprazole sodium inj 4pantoprazole sodium tbec 2 QL(60/30)

GeneticorEnzymeDisorder:Replacement,Modifiers,Treatment

GeneticorEnzymeDisorder:Replacement,Modifiers,TreatmentALDURAZYME 5 PA NDSCEREZYME 5 B/D PA NDS

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clodan 4cortisone acetate 4DEPO-MEDROL INJ 20MG/ML 4desonide lotn 4desonide oint 4desoximetasone crea 4desoximetasone gel 4desoximetasone oint 4dexamethasone elix 2dexamethasone intensol 4dexamethasone oral soln 2dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

4

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

fludrocortisone acetate 2fluocinolone acetonide 4fluocinolone acetonide body 4fluocinolone acetonide scalp 4fluocinonide crea 0.1% 4fluocinonide crea 0.05% 3fluocinonide external soln 4fluocinonide gel 4fluocinonide oint 4fluticasone propionate crea 2fluticasone propionate oint 4halobetasol propionate crea 4halobetasol propionate oint 4hydrocortisone butyrate (lipid) 4hydrocortisone butyrate (lipophilic)

4

hydrocortisone butyrate crea 4hydrocortisone butyrate external soln

4

hydrocortisone butyrate oint 4hydrocortisone external crea 1hydrocortisone lotn 2.5% 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

finasteride tabs 5mg 2 QL(30/30)tamsulosin hydrochloride 2 QL(60/30)Genitourinary Agents, Otherbethanechol chloride 3ELMIRON 4phenazopyridine hydrochloride 2phenazopyridine hydrocholride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 4ala-cort crea 1% 1alclometasone dipropionate 2augmented betamethasone dipropionate crea

2

augmented betamethasone dipropionate gel

3

augmented betamethasone dipropionate lotn

4

augmented betamethasone dipropionate oint

4

betamethasone dipropionate 3betamethasone valerate crea 2betamethasone valerate foam 4betamethasone valerate lotn 2betamethasone valerate oint 2clobetasol propionate crea 2clobetasol propionate emollient crea

2

clobetasol propionate emollient foam

4

clobetasol propionate external soln

2

clobetasol propionate foam 4clobetasol propionate gel 2clobetasol propionate liqd 4clobetasol propionate lotn 4clobetasol propionate oint 2clobetasol propionate sham 4CLOBEX 4

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

triamcinolone acetonide crea 0.025%, 0.5%

2

triamcinolone acetonide inj 40mg/ml

4

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2triderm crea 0.1% 2

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)desmopressin acetate inj 4desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2GENOTROPIN 5 PA NDSGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA NDS

GENOTROPIN MINIQUICK INJ 0.2MG

4 PA

INCRELEX 4 PASTIMATE 5 NDS

Hormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PA NDSoxandrolone tabs 10mg 4 PA QL(60/30)oxandrolone tabs 2.5mg 3 PA QL(120/30)Androgensdanazol caps 50mg 3danazol caps 100mg, 200mg 4testosterone cypionate 4testosterone enanthate 4 QL(5/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 2hydrocortisone tabs 2hydrocortisone valerate 4MEDROL TABS 2MG 3methylprednisolone acetate inj 80mg/ml

4

methylprednisolone dose pack 2methylprednisolone sodiumsuccinate inj 125mg, 40mg

4

methylprednisolone tabs 2mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2prednicarbate oint 2prednisolone 4prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

4

prednisone intensol 4prednisone oral soln 2prednisone tabs 50mg 2prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

prednisone tbpk 1procto-med hc 2procto-pak 2proctosol hc 2proctozone-hc 2SOLU-CORTEF 4TEXACORT 3triamcinolone acetonide crea 0.1%

1

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

elinest 3emoquette 2enpresse-28 2enskyce 3estarylla 2estradiol crea 4estradiol pttw 4 PA QL(8/28)estradiol ptwk 4 PA QL(4/28)estradiol tabs 10mcg 4 QL(18/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol valerate 4ESTRING 4 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

4

falmina 2femynor 2fyavolv tabs 2.5mcg; 0.5mg 4 PAhailey 24 fe 3introvale 4 QL(91/91)isibloom 3jolessa 3 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2kariva 2kelnor 1/35 2kelnor 1/50 2kurvelo 3larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 0; 0

3 QL(91/91)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

testosterone gel 25mg/2.5gm, 50mg/5gm

4 PA QL(300/30)

testosterone pump gel 1% 4 PA QL(300/30)EstrogensALORA 3 PA QL(8/28)altavera 3alyacen 1/35 2alyacen 7/7/7 3amethia 3 QL(91/91)amethia lo 2 QL(91/91)apri 2aranelle 4ashlyna 4 QL(91/91)aubra 3aviane 2azurette 3balziva 2blisovi fe 1.5/30 2briellyn 2camrese 3 QL(91/91)camrese lo 4 QL(91/91)caziant 2cesia 3chateal 3cryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 3cyred eq 2dasetta 1/35 3dasetta 7/7/7 3daysee 3 QL(91/91)DELESTROGEN INJ 10MG/ML 4delyla 3DEPO-ESTRADIOL 4desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg

3

desogestrel/ethinyl estradiol tabs 0; 0

2

dotti 2 PA QL(8/28)

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

orsythia 2philith 3pimtrea 3pirmella 1/35 2pirmella 7/7/7 3portia-28 2PREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 4 PA QL(30/30)previfem 2reclipsen 2setlakin 4 QL(91/91)sprintec 28 2sronyx 2tarina fe 1/20 3tri-estarylla 3tri-legest fe 3tri-linyah 3tri-mili 2tri-previfem 2tri-sprintec 2tri-vylibra 2trivora-28 2tydemy 2velivet 2vienva 2viorele 3vyfemla 2vylibra 2wera 3yuvafem 4 QL(18/28)zovia 1/35e 2Progesterone Agonists/AntagonistsELLA 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg

3

levonorgestrel/ethinyl estradiol tabs 0; 0, 20mcg; 0.1mg

4

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

4 QL(91/91)

levora 0.15/30-28 2low-ogestrel 2lutera 3marlissa 2melodetta 24 fe 2MENEST 4 PAMENOSTAR 3 PA QL(4/28)mibelas 24 fe 2microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2mili 2MINIVELLE 4 PA QL(8/28)mono-linyah 3necon 0.5/35-28 3norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

4 PA

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

3

norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg

3

norgestimate/ethinyl estradiol tabs 0; 0

2

nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2ogestrel 3

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

liothyronine sodium tabs 2SYNTHROID 4UNITHROID 4

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5 NDS

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 4 QL(16/28)ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA NDS

QL(4/365)leuprolide acetate 4 PALUPRON DEPOT (1-MONTH) 5 PA NDS QL(1/30)LUPRON DEPOT (3-MONTH) 5 PA QL(1/84)LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA NDS QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate 4 PASIGNIFOR 5 PA NDS QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 PA NDS QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

5 PA NDS QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 PA NDS QL(0.5/28)

SOMAVERT 5 PA NDS QL(30/30)SYNAREL 5 PA NDSTRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA NDS QL(1/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MAKENA 5 PA NDSProgestinscamila 2deblitane 2DEPO-PROVERA 4 QL(10/28)errin 2heather 3hydroxyprogesterone caproate 5 PA NDSincassia 2jencycla 3lyza 3MAKENA 5 PA NDSmedroxyprogesterone acetate inj

4 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

4 PA

megestrol acetate tabs 20mg 4 PAmegestrol acetate tabs 40mg 3 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 3progesterone caps 2sharobel 2Selective Estrogen Receptor Modifying AgentsDUAVEE 4 PA QL(30/30)raloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG

4

levoxyl tabs 100mcg, 112mcg, 175mcg

4

liothyronine sodium inj 4

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH)

5 PA NDS QL(4/365)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK)

5 PA NDS QL(6/365)

HUMIRA PEN 5 PA NDS QL(4/28)HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML

5 PA NDS QL(6/365)

HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML

5 PA NDS QL(12/365)

HUMIRA PEN-PS/UV STARTER INJ

5 PA NDS QL(6/365)

HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML

5 PA NDS QL(8/365)

methotrexate sodium 4methotrexate tabs 2mycophenolate mofetil caps 4 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PA NDSmycophenolate mofetil tabs 4 PAmycophenolic acid dr 4 PANULOJIX 5 PA NDS QL(150/30)PROGRAF INJ 4 PAPROGRAF PACK 4 PARAPAMUNE ORAL SOLN 5 PA NDSRENFLEXIS 5 PA NDSSANDIMMUNE ORAL SOLN 4 PAsirolimus oral soln 5 PA NDSsirolimus tabs 4 PASKYRIZI 5 PA NDS QL(2/28)tacrolimus caps 3 PATORISEL 5 B/D PA NDS

QL(4/28)XATMEP 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

TRIPTODUR 5 PA NDS QL(1/168)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 4

Immunological Agents

Angioedema AgentsCINRYZE 5 PA NDS QL(20/30)FIRAZYR 5 PA NDS QL(18/30)icatibant acetate 5 PA NDS QL(18/30)RUCONEST 5 PA NDS QL(8/30)Immune SuppressantsASTAGRAF XL 4 PAAZASAN 3 PAazathioprine inj 4 PAazathioprine tabs 2 PAcyclosporine 4 PAcyclosporine modified 4 PAENBREL INJ 25MG/0.5ML 5 PA NDS

QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA NDS QL(8/28)ENBREL MINI 5 PA NDS QL(8/28)ENBREL SURECLICK 5 PA NDS QL(8/28)ENVARSUS XR TB24 4MG 5 PA NDSENVARSUS XR TB24 0.75MG, 1MG

4 PA

gengraf 4 PAHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML

5 PA NDS QL(2/28)

HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML

5 PA NDS QL(4/28)

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GARDASIL 9 4 QL(1.5/365)HAVRIX 4HEPLISAV-B 4 B/D PA QL(3/365)HIBERIX 4IMOVAX RABIES (H.D.C.V.) 4 B/D PAINFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4KINRIX 4M-M-R II 4 QL(2/365)MENACTRA 4MENVEO 4PEDIARIX 4PEDVAX HIB 4PROQUAD 4 QL(2/365)QUADRACEL 4RABAVERT 4 B/D PARECOMBIVAX HB 4 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3SHINGRIX 4 QL(2/999)STAMARIL 4 QL(1/999)TDVAX 4TENIVAC 4 QL(0.5/28)TRUMENBA 4TWINRIX 4TYPHIM VI 4VAQTA 4VARIVAX 4 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 4YF-VAX 4ZOSTAVAX 4 QL(1/999)

InflammatoryBowelDiseaseAgents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 4mesalamine dr tbec 1.2gm 4 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZORTRESS TABS 0.25MG 4 PA QL(60/30)ZORTRESS TABS 0.75MG, 1MG

5 PA NDS QL(60/30)

ZORTRESS TABS 0.5MG 5 PA NDS QL(120/30)Immunizing Agents, PassiveATGAM 4 PAGAMMAKED INJ 1GM/10ML 3 B/D PAGAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML

5 B/D PA NDS

GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA NDS

GAMUNEX-C INJ 1GM/10ML 4 B/D PATHYMOGLOBULIN 3 B/D PAImmunomodulatorsACTEMRA ACTPEN 5 PA NDS QL(3.6/28)ACTEMRA INJ 162MG/0.9ML 5 PA NDS QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA NDS QL(40/28)

ACTIMMUNE 5 PA NDSARCALYST 5 PA NDSBENLYSTA INJ 400MG 5 PA NDS QL(9/28)BENLYSTA INJ 120MG 5 PA NDS QL(30/28)leflunomide 3 QL(30/30)RINVOQ 5 PA NDS QL(30/30)SIMULECT 5 B/D PA NDSSYNAGIS 5 PA NDSVaccinesACTHIB 4ADACEL 4 QL(0.5/365)BCG VACCINE 4BEXSERO 4BOOSTRIX 4 QL(0.5/365)DAPTACEL 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B INJ 10MCG/0.5ML 4 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 4 B/D PA QL(8/365)

59



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XGEVA 5 PA NDS QL(1.7/28)zoledronic acid inj 5mg/100ml 4 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAMINO ACID 4 B/D PABD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2”

6 QL(200/30)

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM

6 QL(200/30)

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM

6 QL(200/30)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”

6 QL(200/30)

BD PEN NEEDLE/MINI/ULTRA-FINE/31G X 5MM

6 QL(200/30)

BD PEN NEEDLE/NANO/ULTRA -FINE/32G X 4MM

6 QL(200/30)

BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM

6 QL(200/30)

FERRIPROX 5 PA NDSFIRDAPSE 5 PA NDSINTRALIPID 4 B/D PAKORLYM 5 PA NDS QL(120/30)LACTATED RINGERS IRRIGATION

4

levocarnitine 2LIPOSYN III 4 B/D PANATPARA 5 PA NDS QL(2/28)NOVOFINE 31 6 QL(200/30)NOVOFINE 32GX6MM 6 QL(200/30)NOVOFINE AUTOCOVER 30GX8MM

6 QL(200/30)

NOVOTWIST 32GX5MM 6 QL(200/30)NUTRILIPID 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mesalamine enem 4mesalamine kit 4Glucocorticoidsbudesonide cpep 4colocort 4hydrocortisone enem 3Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

BINOSTO 4calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 4calcitriol oral soln 2doxercalciferol caps 0.5mcg 4 QL(90/30)doxercalciferol caps 2.5mcg 4 QL(120/30)doxercalciferol caps 1mcg 4 QL(240/30)etidronate disodium 2FORTEO 5 PA NDS QL(2.4/28)ibandronate sodium tabs 3 QL(1/28)MIACALCIN 5 NDSpamidronate disodium 4 B/D PAparicalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 4 QL(90/30)PROLIA 4 QL(1/180)SENSIPAR TABS 30MG, 60MG 5 NDS QL(60/30)SENSIPAR TABS 90MG 5 NDS QL(120/30)TYMLOS 5 PA NDS

QL(1.56/30)

60


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Ophthalmic Anti-allergy Agentsazelastine hcl ophthalmic soln 4cromolyn sodium ophthalmic soln

2

epinastine hcl 4olopatadine hcl ophthalmic soln 4 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

4

PAZEO 3 QL(2.5/30)OphthalmicAnti-inflammatoriesbromfenac 4dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3fluorometholone 3flurbiprofen sodium 2ILEVRO 3INVELTYS 4ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4LOTEMAX SM 4neomycin/polymyxin/dexamethasone

2

PRED MILD 3PRED-G 3PRED-G S.O.P. 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic soln

2

PROLENSA 3TOBRADEX OINT 3tobramycin/dexamethasone 3Ophthalmic Antiglaucoma Agentsacetazolamide er 4ALPHAGAN P OPHTHALMIC SOLN 0.1%

4

apraclonidine 4AZOPT 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)PHYSIOLYTE 4physiosol irrigation 4RINGERS IRRIGATION 4sodium chloride irrigation 0.9% 4sterile water irrigation 4sterile water irrigation plastic bottle

4

sterile water irrigation w/hanger 4TECHLITE PEN NEEDLES/31G X 6 MM

6 QL(200/30)

TECHLITE PEN NEEDLES/31G X 8MM

6 QL(200/30)


6 QL(200/30)


6 QL(200/30)


6 QL(200/30)

TIS-U-SOL 4V-GO 20 3V-GO 30 3V-GO 40 3

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)COMBIGAN 3latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 3CYSTARAN 5 PA NDS QL(60/28)proparacaine hcl 1RESTASIS 3 QL(60/30)RHOPRESSA 4 STtropicamide 2

61



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 3 QL(50/30)fluticasone propionate susp 2 QL(16/30)mometasone furoate susp 4 QL(34/30) STNASONEX 4 QL(34/30) STAntihistaminesazelastine hcl nasal soln 4 QL(30/25)azelastine hydrochloride nasal soln

4 QL(30/25)

desloratadine 4 QL(30/30)diphenhydramine hcl inj 4diphenhydramine hydrochloride inj

4

levocetirizine dihydrochloride oral soln

4 QL(300/30)

levocetirizine dihydrochloride tabs

2 QL(30/30)

Antileukotrienesmontelukast sodium chew 2 QL(30/30)montelukast sodium pack 4 QL(30/30)montelukast sodium tabs 2 QL(30/30)zafirlukast 4 QL(60/30)Bronchodilators, AnticholinergicATROVENT HFA 4 QL(25.8/30)COMBIVENT RESPIMAT 4 QL(8/30)INCRUSE ELLIPTA 3 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

betaxolol hcl ophthalmic soln 4brimonidine tartrate ophthalmic soln 0.2%

2

brimonidine tartrate ophthalmic soln 0.15%

3

carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)levobunolol hcl 1PHOSPHOLINE IODIDE 4pilocarpine hcl 4ROCKLATAN 4 STSIMBRINZA 4timolol maleate ophthalmic gel forming

4

timolol maleate ophthalmic soln 1

Otic Agents

Otic Agentsacetic acid 2flac 4fluocinolone acetonide 4fluocinolone acetonide ear drops

4

hydrocortisone/acetic acid 4neomycin/polymyxin/hc 4neomycin/polymyxin/hydrocortisone

4

Respiratory Tract/Pulmonary Agents

Anti-inflammatories,InhaledCorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ARNUITY ELLIPTA 3 QL(30/30)BREO ELLIPTA 3 QL(60/30)budesonide susp 4 B/D PA QL(120/30)

62


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP TABS 500MCG 4 PA QL(30/30)DALIRESP TABS 250MCG 4 PA QL(60/365)THEO-24 4theophylline er tb12 300mg 2theophylline er tb24 2Pulmonary AntihypertensivesADEMPAS 5 PA NDS QL(90/30)ambrisentan 5 PA NDS QL(30/30)bosentan 5 PA NDS QL(60/30)LETAIRIS 5 PA NDS QL(30/30)OPSUMIT 5 PA NDS QL(30/30)REMODULIN 5 B/D PA NDSsildenafil citrate tabs 20mg 3 PA QL(90/30)TRACLEER TABS 5 PA NDS QL(60/30)TRACLEER TBSO 5 PA NDStreprostinil 5 B/D PA NDSVENTAVIS 5 PA NDS QL(270/30)Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA NDS QL(270/30)ESBRIET TABS 801MG 5 PA NDS QL(90/30)ESBRIET TABS 267MG 5 PA NDS QL(270/30)OFEV 5 PA NDS QL(60/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 4 B/D PAARALAST NP 5 B/D PA NDSPROLASTIN-C 5 B/D PA NDSribavirin inhalation soln 5 B/D PA NDSTRELEGY ELLIPTA 3 QL(60/30)XOLAIR INJ 75MG/0.5ML 5 PA NDS QL(2/28)XOLAIR INJ 150MG/ML 5 PA NDS QL(4/28)XOLAIR VIAL INJ 150MG 5 PA NDS QL(6/28)ZEMAIRA 5 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 4albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 2albuterol sulfate tabs 4ANORO ELLIPTA 3 QL(60/30)epinephrine hcl inj 1mg/10ml 4epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)levalbuterol tartrate hfa 4 QL(30/30)metaproterenol sulfate 4PERFOROMIST 4 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate 4VENTOLIN HFA 4 QL(36/30)Cystic Fibrosis AgentsCAYSTON 5 PA NDS QL(84/56)KALYDECO 5 PA NDS QL(60/30)ORKAMBI PACK 5 PA NDS QL(56/28)ORKAMBI TABS 5 PA NDS QL(120/30)PULMOZYME 5 B/D PA NDS

QL(150/30)TOBI PODHALER 5 NDS QL(1568/365)tobramycin nebu 5 B/D PA NDS

63



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hydrochloride tabs 10mg, 5mg

2 PA QL(90/30)

methocarbamol tabs 2 PAorphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam caps 15mg, 30mg 2 QL(60/365)temazepam caps 22.5mg, 7.5mg

4 QL(60/365)

zaleplon 2 QL(30/30)zolpidem tartrate tabs 2 QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)ramelteon 3 QL(30/30)ROZEREM 3 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA NDS QL(540/30)

64

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir oral soln . . . . . . . . . . . . . . . . . 37abacavir sulfate/lamivudine . . . . . . . . 37abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 37abacavir tabs . . . . . . . . . . . . . . . . . . . . . 37ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 28ABILIFY MAINTENA . . . . . . . . . . . . . . . 35abiraterone acetate . . . . . . . . . . . . . . . . 30ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 31acamprosate calcium dr . . . . . . . . . . . . 21acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 39acebutolol hcl caps 200mg . . . . . . . . . 43acebutolol hydrochloride caps 400mg . . . . . . . . . . . . . . . . . . . . . . . 43acetaminophen/codeine oral soln . . 19acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 19acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 19acetazolamide . . . . . . . . . . . . . . . . . . . . . 44acetazolamide er . . . . . . . . . . . . . . . . . . 60acetazolamide sodium . . . . . . . . . . . . . 45acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 61acetylcysteine inhalation soln . . . . . . 62acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ACTEMRA ACTPEN . . . . . . . . . . . . . . . 58ACTEMRA INJ 162MG/0.9ML . . . . . . 58ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 58ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 58acyclovir caps . . . . . . . . . . . . . . . . . . . . 38acyclovir oint . . . . . . . . . . . . . . . . . . . . . 38acyclovir sodium . . . . . . . . . . . . . . . . . . . 38acyclovir susp . . . . . . . . . . . . . . . . . . . . 38acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 38ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 58adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 37ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 62

adriamycin inj 2mg/ml . . . . . . . . . . . . . . 31ADRIAMYCIN INJ 50MG . . . . . . . . . . . 31adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 61ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 61AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . 33AFINITOR DISPERZ TBSO 5MG . . . 33AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 33AFINITOR TABS 10MG . . . . . . . . . . . . 33ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 52albendazole . . . . . . . . . . . . . . . . . . . . . . . 34ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 34albuterol sulfate er . . . . . . . . . . . . . . . . . 62albuterol sulfate nebu 0.5% . . . . . . . . 62albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 62albuterol sulfate syrp . . . . . . . . . . . . . . 62albuterol sulfate tabs . . . . . . . . . . . . . . 62alclometasone dipropionate . . . . . . . . 52ALCOHOL PREP PADS . . . . . . . . . . . . 21ALDURAZYME . . . . . . . . . . . . . . . . . . . . 51ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 33alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 59alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 59alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 51ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 34ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 34ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 33aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 44allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 29allopurinol sodium . . . . . . . . . . . . . . . . . 29ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 54alosetron hydrochloride tabs 0.5mg . . 50alosetron hydrochloride tabs 1mg . . . 50ALPHAGAN P OPHTHALMIC SOLN 0.1% . . . . . . . . 60

alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 39alprazolam odt tbdp 2mg . . . . . . . . . . . 39alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 39alprazolam tabs 2mg . . . . . . . . . . . . . . 39altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ALUNBRIG TABS 30MG . . . . . . . . . . . 33ALUNBRIG TABS 180MG, 90MG . . . 33ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 33alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 54alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 54amantadine hcl . . . . . . . . . . . . . . . . . . . . 35AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 28ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 62a-methapred . . . . . . . . . . . . . . . . . . . . . . 52amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 54amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 54amikacin sulfate . . . . . . . . . . . . . . . . . . . 21amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 45amiloride/hydrochlorothiazide . . . . . . 45AMINO ACID . . . . . . . . . . . . . . . . . . . . . . 59aminophylline . . . . . . . . . . . . . . . . . . . . . 62AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 48AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 48AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 48amiodarone hcl inj 50mg/ml, 900mg/18ml . . . . . . . . . . . . . 43amiodarone hcl tabs 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 43amiodarone hcl tabs 400mg . . . . . . . . 43amiodarone hydrochloride inj . . . . . . 43AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 51amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 28amitriptyline hydrochloride tabs 10mg, 50mg . . . . . . . . . . . . . . . . . . 28amlodipine besylate/benazepril hcl caps 5mg; 40mg . . . . . . . . . . . . . . . 44amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 44

65


Covered Drugs Index

ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 58aripiprazole odt . . . . . . . . . . . . . . . . . . . . 35aripiprazole oral soln . . . . . . . . . . . . . . 35aripiprazole tabs . . . . . . . . . . . . . . . . . . 35ARISTADA INITIO . . . . . . . . . . . . . . . . . 35ARISTADA INJ 441MG/1.6ML . . . . . . 35ARISTADA INJ 662MG/2.4ML . . . . . . 35ARISTADA INJ 882MG/3.2ML . . . . . . 35ARISTADA INJ 1064MG/3.9ML . . . . . 36armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 63ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 61ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 31arsenic trioxide . . . . . . . . . . . . . . . . . . . . 31ascomp/codeine . . . . . . . . . . . . . . . . . . . 19ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 54aspirin/dipyridamole . . . . . . . . . . . . . . . 42ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 57atazanavir sulfate caps 150mg . . . . . 38atazanavir sulfate caps 200mg . . . . . 38atazanavir sulfate caps 300mg . . . . . 38atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 43atenolol/chlorthalidone . . . . . . . . . . . . . 43ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 58atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 46atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 46atorvastatin calcium . . . . . . . . . . . . . . . 45atovaquone . . . . . . . . . . . . . . . . . . . . . . . 34atovaquone/proguanil hcl . . . . . . . . . . 34ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 38atropine sulfate inj 0.5mg/5ml . . . . . . 44atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml . . . . 50atropine sulfate ophthalmic soln . . . . 60ATROVENT HFA . . . . . . . . . . . . . . . . . . 61aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54augmented betamethasone dipropionate crea . . . . . . . . . . . . . . . . . 52augmented betamethasone dipropionate gel . . . . . . . . . . . . . . . . . . . 52

AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 47ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 53anagrelide hydrochloride . . . . . . . . . . . 41anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 50anastrozole . . . . . . . . . . . . . . . . . . . . . . . 32ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 62APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 35apraclonidine . . . . . . . . . . . . . . . . . . . . . . 60aprepitant caps 40mg . . . . . . . . . . . . . . 28aprepitant caps 80mg . . . . . . . . . . . . . . 28aprepitant caps 125mg . . . . . . . . . . . . . 28aprepitant caps pack . . . . . . . . . . . . . . . 28apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 58APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 25APTIOM TABS 600MG . . . . . . . . . . . . . 25APTIVUS CAPS . . . . . . . . . . . . . . . . . . 38APTIVUS ORAL SOLN . . . . . . . . . . . . 38ARALAST NP . . . . . . . . . . . . . . . . . . . . . 62aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 41ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 41ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 41

amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 44amlodipine besylate tabs 2.5mg . . . . 44amlodipine besylate tabs 5mg . . . . . . 44amlodipine besylate tabs 10mg . . . . . 44amlodipine besylate/valsartan . . . . . . 44amlodipine/valsartan/hctz . . . . . . . . . . 44amlodipine/valsartan/ hydrochlorothiazide tabs 5mg; 12.5mg; 160mg . . . . . . . . . . . . . . 44ammonium lactate . . . . . . . . . . . . . . . . . 47amnesteem . . . . . . . . . . . . . . . . . . . . . . . 47amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 28amoxicillin caps . . . . . . . . . . . . . . . . . . . 23amoxicillin chew . . . . . . . . . . . . . . . . . . 23amoxicillin/clavulanate potassium . . . 23amoxicillin/clavulanate potassium er . . . . . . . . . . . . . . . . . . . . . . 23amoxicillin susr . . . . . . . . . . . . . . . . . . . 23amoxicillin tabs . . . . . . . . . . . . . . . . . . . 23amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 46amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . . . . . . . . 46amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 46amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 46amphotericin b . . . . . . . . . . . . . . . . . . . . 28ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 23ampicillin sodium . . . . . . . . . . . . . . . . . . 23ampicillin-sulbactam . . . . . . . . . . . . . . . 23

66


Covered Drugs Index

betamethasone dipropionate . . . . . . . 52betamethasone valerate crea . . . . . . 52betamethasone valerate foam . . . . . 52betamethasone valerate lotn . . . . . . . 52betamethasone valerate oint . . . . . . . 52BETASERON . . . . . . . . . . . . . . . . . . . . . 47betaxolol hcl ophthalmic soln . . . . . . 61betaxolol hcl tabs . . . . . . . . . . . . . . . . . 43bethanechol chloride . . . . . . . . . . . . . . . 52bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 34BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 58bicalutamide . . . . . . . . . . . . . . . . . . . . . . 30BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 23BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 37BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 34bimatoprost ophthalmic soln . . . . . . . 60BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 59bisoprolol fumarate . . . . . . . . . . . . . . . . 43bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 43bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . 31bleomycin sulfate . . . . . . . . . . . . . . . . . . 31BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 24BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 24blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 54BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 58BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 31bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 62BOSULIF TABS 100MG . . . . . . . . . . . . 33BOSULIF TABS 400MG, 500MG . . . 33BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 31BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 61briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 42brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 61brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 61

BALVERSA TABS 3MG . . . . . . . . . . . . 33BALVERSA TABS 4MG . . . . . . . . . . . . 33BALVERSA TABS 5MG . . . . . . . . . . . . 33balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54BANZEL SUSP . . . . . . . . . . . . . . . . . . . 26BANZEL TABS 200MG . . . . . . . . . . . . 26BANZEL TABS 400MG . . . . . . . . . . . . 26BAQSIMI ONE PACK . . . . . . . . . . . . . . 40BAQSIMI TWO PACK . . . . . . . . . . . . . . 40BARACLUDE ORAL SOLN . . . . . . . . 37BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 34BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 24BCG VACCINE . . . . . . . . . . . . . . . . . . . . 58BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” . . . . 59BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” . . . . 59BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM . . . . . . . . 59BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM . . . . . . . . . . . . . 59BD PEN NEEDLE/MINI/ ULTRA-FINE/31G X 5MM . . . . . . . . . . 59BD PEN NEEDLE/NANO/ ULTRA -FINE/32G X 4MM . . . . . . . . . 59BD PEN NEEDLE/ORIGINAL/ ULTRA-FINE/29G X 12.7MM . . . . . . . 59BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 31benazepril hcl . . . . . . . . . . . . . . . . . . . . . 42benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 42benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 42benazepril hydrochloride . . . . . . . . . . . 42BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 30BENLYSTA INJ 120MG . . . . . . . . . . . . 58BENLYSTA INJ 400MG . . . . . . . . . . . . 58benztropine mesylate inj . . . . . . . . . . . 35benztropine mesylate tabs . . . . . . . . . 35BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 24BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 34

augmented betamethasone dipropionate lotn . . . . . . . . . . . . . . . . . . 52augmented betamethasone dipropionate oint . . . . . . . . . . . . . . . . . . 52AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 23AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 50AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 34AVELOX . . . . . . . . . . . . . . . . . . . . . . . . . . 24aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54avita crea . . . . . . . . . . . . . . . . . . . . . . . . . 47avita gel . . . . . . . . . . . . . . . . . . . . . . . . . . 47AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 47AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 47azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 31AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 23AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 57AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 24azathioprine inj . . . . . . . . . . . . . . . . . . . 57azathioprine tabs . . . . . . . . . . . . . . . . . 57azelastine hcl nasal soln . . . . . . . . . . . 61azelastine hcl ophthalmic soln . . . . . 60azelastine hydrochloride nasal soln . . 61azithromycin inj . . . . . . . . . . . . . . . . . . . 24azithromycin pack . . . . . . . . . . . . . . . . . 24azithromycin susr 100mg/5ml . . . . . . 24azithromycin susr 200mg/5ml . . . . . . 24azithromycin tabs 250mg, 500mg . . . 24azithromycin tabs 600mg . . . . . . . . . . . 24AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 60aztreonam inj 1gm . . . . . . . . . . . . . . . . . 23aztreonam inj 2gm . . . . . . . . . . . . . . . . . 23azurette . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Bbacitracin inj . . . . . . . . . . . . . . . . . . . . . . 21bacitracin ophthalmic oint . . . . . . . . . . 21bacitracin/polymyxin b . . . . . . . . . . . . . 21baclofen tabs . . . . . . . . . . . . . . . . . . . . . 36balsalazide disodium . . . . . . . . . . . . . . 58

67


Covered Drugs Index

carbidopa/levodopa . . . . . . . . . . . . . . . . 35carbidopa/levodopa/entacapone . . . . 35carbidopa/levodopa er . . . . . . . . . . . . . 35carbidopa/levodopa odt . . . . . . . . . . . . 35carboplatin inj 150mg/15ml . . . . . . . . . 31carboplatin inj 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 30carmustine . . . . . . . . . . . . . . . . . . . . . . . . 30carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 61cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 44carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 43carvedilol phosphate . . . . . . . . . . . . . . . 43caspofungin acetate . . . . . . . . . . . . . . . 28CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 62caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . 22cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 22cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 22CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 22cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 23cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg . . . . . . . . 23cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 23cefepime/dextrose . . . . . . . . . . . . . . . . . 23cefixime caps . . . . . . . . . . . . . . . . . . . . . 23cefixime susr . . . . . . . . . . . . . . . . . . . . . 23cefotaxime sodium inj 1gm, 500mg . . 23cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 23cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 23cefpodoxime proxetil . . . . . . . . . . . . . . . 23cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 23ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 23ceftazidime/dextrose . . . . . . . . . . . . . . . 23ceftriaxone in iso-osmotic dextrose . . 23ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 23cefuroxime axetil . . . . . . . . . . . . . . . . . . 23cefuroxime sodium . . . . . . . . . . . . . . . . 23

BYETTA INJ 5MCG/0.02ML . . . . . . . . 39BYETTA INJ 10MCG/0.04ML . . . . . . . 39BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 43BYSTOLIC TABS 20MG . . . . . . . . . . . 43

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 56CABOMETYX TABS 20MG, 60MG . 33CABOMETYX TABS 40MG . . . . . . . . 33calcipotriene crea . . . . . . . . . . . . . . . . . 47calcipotriene external soln . . . . . . . . . 47calcipotriene oint . . . . . . . . . . . . . . . . . . 47calcitonin-salmon . . . . . . . . . . . . . . . . . . 59calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 47calcitriol caps . . . . . . . . . . . . . . . . . . . . . 59calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 59calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 47calcitriol oral soln . . . . . . . . . . . . . . . . . 59calcium acetate caps . . . . . . . . . . . . . . 50calcium acetate tabs 667mg . . . . . . . . 50CALQUENCE . . . . . . . . . . . . . . . . . . . . . 33camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 54camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 54candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 42candesartan cilexetil tabs 16mg, 4mg, 8mg . . . . . . . . . . . . . . 42candesartan cilexetil tabs 32mg . . . . 42CAPASTAT SULFATE . . . . . . . . . . . . . . 30CAPRELSA TABS 100MG . . . . . . . . . 33CAPRELSA TABS 300MG . . . . . . . . . 33captopril . . . . . . . . . . . . . . . . . . . . . . . . . . 42captopril/hydrochlorothiazide . . . . . . . 42CARAFATE SUSP . . . . . . . . . . . . . . . . 51CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 48carbamazepine . . . . . . . . . . . . . . . . . . . . 26carbamazepine er cp12 . . . . . . . . . . . 26carbamazepine er tb12 . . . . . . . . . . . . 26

BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 25BRIVIACT ORAL SOLN . . . . . . . . . . . 25BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 25BRIVIACT TABS 100MG . . . . . . . . . . . 25bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 60bromocriptine mesylate . . . . . . . . . . . . 35budesonide cpep . . . . . . . . . . . . . . . . . 59budesonide susp . . . . . . . . . . . . . . . . . . 61bumetanide inj . . . . . . . . . . . . . . . . . . . . 45bumetanide tabs 0.5mg, 1mg . . . . . . . 45bumetanide tabs 2mg . . . . . . . . . . . . . . 45buprenorphine hcl inj . . . . . . . . . . . . . . 19buprenorphine hcl/naloxone hcl . . . . . 21buprenorphine hcl subl . . . . . . . . . . . . 21buprenorphine hydrochloride/ naloxone hydrochloride film . . . . . . . . 21bupropion hcl tabs 100mg . . . . . . . . . . 27bupropion hydrochloride er (sr) . . . . . 21bupropion hydrochloride er (sr) . . . . . 27bupropion hydrochloride er (xl) tb24 150mg, 300mg . . . . . . . . . . . . . . . 27bupropion hydrochloride tabs 75mg . . 27buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 39buspirone hydrochloride tabs 10mg, 5mg, 7.5mg . . . . . . . . . . . . 39busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 30BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 30butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 19butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . 19butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . 19butalbital/aspirin/caffeine caps . . . . . 19butalbital/aspirin/caffeine/codeine . . . 19butorphanol tartrate inj 1mg/ml . . . . . 19butorphanol tartrate inj 2mg/ml . . . . . 19butorphanol tartrate nasal soln . . . . . 19BYDUREON BCISE . . . . . . . . . . . . . . . 39BYDUREON PEN . . . . . . . . . . . . . . . . . 39

68


Covered Drugs Index

clobetasol propionate emollient crea . . . . . . . . . . . . . . . . . . . . 52clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 52clobetasol propionate external soln . . 52clobetasol propionate foam . . . . . . . . 52clobetasol propionate gel . . . . . . . . . . 52clobetasol propionate liqd . . . . . . . . . 52clobetasol propionate lotn . . . . . . . . . 52clobetasol propionate oint . . . . . . . . . 52clobetasol propionate sham . . . . . . . . 52CLOBEX . . . . . . . . . . . . . . . . . . . . . . . . . . 52clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 31clomipramine hcl . . . . . . . . . . . . . . . . . . 28clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 25clonazepam odt tbdp 1mg . . . . . . . . . . 25clonazepam odt tbdp 2mg . . . . . . . . . . 25clonazepam tabs 0.5mg . . . . . . . . . . . . 25clonazepam tabs 1mg . . . . . . . . . . . . . 25clonazepam tabs 2mg . . . . . . . . . . . . . 25clonidine hcl er . . . . . . . . . . . . . . . . . . . . 46clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 42clonidine hcl ptwk 0.3mg/24hr . . . . . . 42clonidine hcl tabs 0.1mg . . . . . . . . . . . 42clonidine hcl tabs 0.3mg . . . . . . . . . . . 42clonidine hydrochloride tabs . . . . . . . 42clopidogrel tabs 75mg . . . . . . . . . . . . . 42clopidogrel tabs 300mg . . . . . . . . . . . . 42clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 39clorazepate dipotassium tabs 15mg . 39clotrimazole/betamethasone dipropionate crea . . . . . . . . . . . . . . . . . 28clotrimazole/betamethasone dipropionate lotn . . . . . . . . . . . . . . . . . . 28clotrimazole external crea . . . . . . . . . 28clotrimazole external soln . . . . . . . . . . 28clotrimazole lozg . . . . . . . . . . . . . . . . . . 28

ciprofloxacin susr . . . . . . . . . . . . . . . . . 24CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 24cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml . . . . . . . . . . 31citalopram hydrobromide oral soln . . 27citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 27citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 27citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 27cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 31claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 47clarithromycin . . . . . . . . . . . . . . . . . . . . . 24clarithromycin er . . . . . . . . . . . . . . . . . . . 24clindacin etz pledgets . . . . . . . . . . . . . . 21clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 21clindamycin hcl caps . . . . . . . . . . . . . . . 21clindamycin phosphate crea . . . . . . . 21clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 21clindamycin phosphate gel . . . . . . . . 21clindamycin phosphate in d5w . . . . . . 22clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml . . . . . . . . . . . . . 22clindamycin phosphate lotn . . . . . . . . 22clindamycin phosphate swab . . . . . . 22clindamycin/sodium chloride . . . . . . . . 22CLINIMIX 4.25%/DEXTROSE 5% . . 48CLINIMIX 4.25%/DEXTROSE 10% . . 48CLINIMIX 4.25%/DEXTROSE 25% . . 48CLINIMIX 5%/DEXTROSE 15% . . . . 48CLINIMIX 5%/DEXTROSE 20% . . . . 48CLINIMIX 5%/DEXTROSE 25% . . . . 48CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 48CLINISOL SF 15% . . . . . . . . . . . . . . . . 48clobazam susp . . . . . . . . . . . . . . . . . . . . 25clobazam tabs . . . . . . . . . . . . . . . . . . . . 25clobetasol propionate crea . . . . . . . . . 52

celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 19celecoxib caps 400mg . . . . . . . . . . . . . 19CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 25cephalexin caps 250mg, 500mg . . . . 23cephalexin susr . . . . . . . . . . . . . . . . . . . 23CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 51cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 21CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 21CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 21chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 49chloramphenicol sodium succinate . . 21chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 47chloroquine phosphate . . . . . . . . . . . . . 34chlorothiazide . . . . . . . . . . . . . . . . . . . . . 45chlorothiazide sodium . . . . . . . . . . . . . . 45chlorpromazine hcl . . . . . . . . . . . . . . . . 35chlorthalidone . . . . . . . . . . . . . . . . . . . . . 45cholestyramine . . . . . . . . . . . . . . . . . . . . 45cholestyramine light . . . . . . . . . . . . . . . 45ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ciclopirox nail lacquer . . . . . . . . . . . . . . 28ciclopirox olamine . . . . . . . . . . . . . . . . . 28ciclopirox sham . . . . . . . . . . . . . . . . . . . 28ciclopirox susp . . . . . . . . . . . . . . . . . . . . 28cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 37cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 42CILOXAN OINT . . . . . . . . . . . . . . . . . . . 24CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 38CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 57CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 24ciprofloxacin hcl tabs 100mg . . . . . . . 24ciprofloxacin hcl tabs 750mg . . . . . . . 24ciprofloxacin hydrochloride . . . . . . . . . 24ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 24

69


Covered Drugs Index

DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML . 31DAURISMO TABS 25MG . . . . . . . . . . 31DAURISMO TABS 100MG . . . . . . . . . 31daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 56decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 31DELESTROGEN INJ 10MG/ML . . . . 54DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 37delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 44DEPEN TITRATABS . . . . . . . . . . . . . . . 49DEPO-ESTRADIOL . . . . . . . . . . . . . . . 54DEPO-MEDROL INJ 20MG/ML . . . . . 52DEPO-PROVERA . . . . . . . . . . . . . . . . . 56DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 38desipramine hcl . . . . . . . . . . . . . . . . . . . 28desloratadine . . . . . . . . . . . . . . . . . . . . . . 61desmopressin acetate inj . . . . . . . . . . 53desmopressin acetate nasal soln . . . 53desmopressin acetate tabs . . . . . . . . 53desogestrel/ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . . . . . . . . . . 54desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg . . . . . . . . . . . . . . . 54desonide lotn . . . . . . . . . . . . . . . . . . . . . 52desonide oint . . . . . . . . . . . . . . . . . . . . . 52desoximetasone crea . . . . . . . . . . . . . 52desoximetasone gel . . . . . . . . . . . . . . . 52desoximetasone oint . . . . . . . . . . . . . . 52desvenlafaxine er . . . . . . . . . . . . . . . . . . 27dexamethasone elix . . . . . . . . . . . . . . . 52dexamethasone intensol . . . . . . . . . . . 52dexamethasone oral soln . . . . . . . . . . 52dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 52dexamethasone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 60dexamethasone tabs 0.5mg, 0.75mg, 4mg . . . . . . . . . . . . . . . 52

cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 54cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 54cyclobenzaprine hydrochloride tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 63cyclophosphamide caps . . . . . . . . . . . 30cyclophosphamide inj . . . . . . . . . . . . . 30cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 30CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 39cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 57cyclosporine modified . . . . . . . . . . . . . . 57CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 34cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 54CYSTADANE . . . . . . . . . . . . . . . . . . . . . 51CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 51CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 60cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 31cytarabine aqueous . . . . . . . . . . . . . . . . 31

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 30dactinomycin . . . . . . . . . . . . . . . . . . . . . . 31dalfampridine er . . . . . . . . . . . . . . . . . . . 47DALIRESP TABS 250MCG . . . . . . . . . 62DALIRESP TABS 500MCG . . . . . . . . . 62danazol caps 50mg . . . . . . . . . . . . . . . . 53danazol caps 100mg, 200mg . . . . . . . 53dantrolene sodium caps . . . . . . . . . . . 36dapsone tabs . . . . . . . . . . . . . . . . . . . . . 30DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 58DAPTOMYCIN INJ 350MG . . . . . . . . . 22daptomycin inj 500mg . . . . . . . . . . . . . . 22DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 34darifenacin hydrobromide er . . . . . . . . 51DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 34dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 54dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 54daunorubicin hcl . . . . . . . . . . . . . . . . . . . 31daunorubicin hydrochloride inj 20mg/4ml . . . . . . . . . . . . . . . . . . . . . . 31

clozapine odt tbdp 12.5mg, 25mg . . . 36clozapine odt tbdp 100mg . . . . . . . . . . 36clozapine odt tbdp 150mg . . . . . . . . . . 36clozapine odt tbdp 200mg . . . . . . . . . . 36clozapine tabs 25mg, 50mg . . . . . . . . 36clozapine tabs 100mg . . . . . . . . . . . . . . 36clozapine tabs 200mg . . . . . . . . . . . . . . 36COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 34colchicine caps . . . . . . . . . . . . . . . . . . . 29colchicine tabs . . . . . . . . . . . . . . . . . . . . 29colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 45colistimethate sodium . . . . . . . . . . . . . . 22colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 59COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 60COMBIVENT RESPIMAT . . . . . . . . . . 61COMETRIQ 60MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 33COMETRIQ 100MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 33COMETRIQ 140MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 33COMPLERA . . . . . . . . . . . . . . . . . . . . . . 37compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 28constulose . . . . . . . . . . . . . . . . . . . . . . . . 51COPAXONE INJ 20MG/ML . . . . . . . . . 47COPAXONE INJ 40MG/ML . . . . . . . . . 47COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 31CORLANOR TABS . . . . . . . . . . . . . . . . 44cortisone acetate . . . . . . . . . . . . . . . . . . 52COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 33COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 41CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 51CRIXIVAN CAPS 200MG . . . . . . . . . . 38CRIXIVAN CAPS 400MG . . . . . . . . . . 38cromolyn sodium conc . . . . . . . . . . . . 50cromolyn sodium nebu . . . . . . . . . . . . 62cromolyn sodium ophthalmic soln . . . 60cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 54CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 49CURITY GAUZE PADS 2”X2” . . . . . . 47

70


Covered Drugs Index

diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg . . . . . 44diltiazem hcl er tb24 . . . . . . . . . . . . . . . 44diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 44diltiazem hcl tabs . . . . . . . . . . . . . . . . . 44diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg . . . . . 44dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44diphenhydramine hcl inj . . . . . . . . . . . 61diphenhydramine hydrochloride inj . . . 61diphenoxylate/atropine . . . . . . . . . . . . . 50DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 58dipyridamole tabs . . . . . . . . . . . . . . . . . 42disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 21divalproex sodium . . . . . . . . . . . . . . . . . 26divalproex sodium dr . . . . . . . . . . . . . . . 26divalproex sodium er . . . . . . . . . . . . . . . 26docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 31DOCETAXEL INJ 200MG/10ML . . . . 31dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 43donepezil hcl tabs 10mg . . . . . . . . . . . 26donepezil hcl tbdp 5mg . . . . . . . . . . . . 26donepezil hcl tbdp 10mg . . . . . . . . . . . 26donepezil hydrochloride tabs 5mg . . 26donepezil hydrochloride tabs 10mg . . 26dorzolamide hcl . . . . . . . . . . . . . . . . . . . 61dorzolamide hcl/timolol maleate . . . . 61dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 37doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 42doxazosin mesylate tabs 8mg . . . . . . 42doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 39doxepin hydrochloride caps 25mg . . 39doxercalciferol caps 0.5mcg . . . . . . . . 59doxercalciferol caps 1mcg . . . . . . . . . . 59doxercalciferol caps 2.5mcg . . . . . . . . 59

DIACOMIT PACK 250MG . . . . . . . . . . 26DIACOMIT PACK 500MG . . . . . . . . . . 26DIASTAT ACUDIAL GEL 10MG . . . . . 26DIASTAT ACUDIAL GEL 20MG . . . . . 26DIASTAT PEDIATRIC . . . . . . . . . . . . . . 26diazepam inj 5mg/ml . . . . . . . . . . . . . . . 39diazepam oral soln . . . . . . . . . . . . . . . . 39diazepam rectal gel gel 2.5mg . . . . . . 26diazepam rectal gel gel 10mg . . . . . . 26diazepam rectal gel gel 20mg . . . . . . 26diazepam tabs . . . . . . . . . . . . . . . . . . . . 39diclofenac potassium . . . . . . . . . . . . . . 19diclofenac sodium dr . . . . . . . . . . . . . . . 19diclofenac sodium er . . . . . . . . . . . . . . . 19diclofenac sodium gel 1% . . . . . . . . . . 47diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 60diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 47dicloxacillin sodium . . . . . . . . . . . . . . . . 23dicyclomine hcl oral soln . . . . . . . . . . . 50dicyclomine hydrochloride caps . . . . 50dicyclomine hydrochloride tabs . . . . 50didanosine . . . . . . . . . . . . . . . . . . . . . . . . 38diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 19digitek tabs 0.25mg . . . . . . . . . . . . . . . . 44digitek tabs 0.125mg . . . . . . . . . . . . . . . 44digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 44digoxin tabs 125mcg . . . . . . . . . . . . . . . 44digoxin tabs 250mcg . . . . . . . . . . . . . . . 44digox tabs 125mcg . . . . . . . . . . . . . . . . 44digox tabs 250mcg . . . . . . . . . . . . . . . . 44dihydroergotamine mesylate inj . . . . . 29dihydroergotamine mesylate nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 29DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 26DILANTIN INFATABS . . . . . . . . . . . . . . 26diltiazem cd cp24 180mg . . . . . . . . . . . 44diltiazem hcl er cp12 . . . . . . . . . . . . . . 44

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 52DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 51dexmethylphenidate hcl tabs 10mg . . 46dexmethylphenidate hydrochloride tabs 2.5mg, 5mg . . . . . 46dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 31dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 46dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 46dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 46dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 46dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 46dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 46dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . 48dextrose 2.5%/nacl 0.45% . . . . . . . . . 48DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 48dextrose5% / electrolyte #48 viaflex . . . . . . . . . . . . . . 48dextrose 5%/lactated ringers . . . . . . . 48dextrose 5%/nacl 0.2% . . . . . . . . . . . . 48DEXTROSE 5%/NACL 0.3% . . . . . . . 48dextrose 5%/nacl 0.9% . . . . . . . . . . . . 48dextrose 5%/nacl 0.33% . . . . . . . . . . . 48dextrose 5%/nacl 0.45% . . . . . . . . . . . 48dextrose 5%/nacl 0.225% . . . . . . . . . . 48DEXTROSE 10% . . . . . . . . . . . . . . . . . . 48dextrose 10%/nacl 0.2% . . . . . . . . . . . 48dextrose10%/nacl 0.45% . . . . . . . . . . . 48DEXTROSE 20% . . . . . . . . . . . . . . . . . . 48DEXTROSE 25% . . . . . . . . . . . . . . . . . . 48DEXTROSE 30% . . . . . . . . . . . . . . . . . . 48DEXTROSE 40% . . . . . . . . . . . . . . . . . . 48DEXTROSE 50% . . . . . . . . . . . . . . . . . . 48DEXTROSE 70% . . . . . . . . . . . . . . . . . . 48DIACOMIT CAPS 250MG . . . . . . . . . . 25DIACOMIT CAPS 500MG . . . . . . . . . . 25

71


Covered Drugs Index

epinastine hcl . . . . . . . . . . . . . . . . . . . . . 60epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . . . . . . . . . . . . . . . . 62epinephrine hcl inj 1mg/10ml . . . . . . . 62EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 62EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 62epirubicin hcl inj 200mg/100ml . . . . . 32epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26EPIVIR HBV ORAL SOLN . . . . . . . . . 37ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 34ergotamine tartrate/caffeine . . . . . . . . 29ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 33ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 30erlotinib hydrochloride tabs 25mg . . . 33erlotinib hydrochloride tabs 100mg, 150mg . . . . . . . . . . . . . . . . . . . . 33errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 23ertapenem sodium . . . . . . . . . . . . . . . . . 23ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 32ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 24ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 24ERYTHROCIN LACTOBIONATE . . . 24erythrocin stearate . . . . . . . . . . . . . . . . . 24erythromycin base . . . . . . . . . . . . . . . . . 24erythromycin/benzoyl peroxide . . . . . 47ERYTHROMYCIN DR . . . . . . . . . . . . . 24erythromycin ethylsuccinate susr 200mg/5ml . . . . . . . . . . . . . . . . . . . 24ERYTHROMYCIN ETHYLSUCCINATE SUSR 400MG/5ML . . . . . . . . . . . . . . . . 24erythromycin ethylsuccinate tabs . . . 24erythromycin external soln . . . . . . . . . 24erythromycin gel . . . . . . . . . . . . . . . . . . 24erythromycin oint . . . . . . . . . . . . . . . . . 24ESBRIET CAPS . . . . . . . . . . . . . . . . . . 62ESBRIET TABS 267MG . . . . . . . . . . . . 62ESBRIET TABS 801MG . . . . . . . . . . . . 62

elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ELIQUIS STARTER PACK . . . . . . . . . 41ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 41ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 41ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 52ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 32EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 30EMEND SUSR . . . . . . . . . . . . . . . . . . . . 28emoquette . . . . . . . . . . . . . . . . . . . . . . . . 54EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 34EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 27EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 38EMTRIVA ORAL SOLN . . . . . . . . . . . . 38enalapril maleate . . . . . . . . . . . . . . . . . . 43enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 43ENBREL INJ 25MG/0.5ML . . . . . . . . . 57ENBREL INJ 25MG, 50MG/ML . . . . . 57ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 57ENBREL SURECLICK . . . . . . . . . . . . . 57endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 20endocet tabs 325mg; 7.5mg . . . . . . . . 20endocet tabs 325mg; 10mg . . . . . . . . 20ENGERIX-B INJ 10MCG/0.5ML . . . . 58ENGERIX-B INJ 20MCG/ML . . . . . . . 58enoxaparin sodium . . . . . . . . . . . . . . . . 41enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 54enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 54entacapone . . . . . . . . . . . . . . . . . . . . . . . 35entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 37ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 42enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 57ENVARSUS XR TB24 4MG . . . . . . . . 57EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 37EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 25

doxorubicin hydrochloride liposomal . . . . . . . . . . . . . . . . . . . . . . . . . 31doxorubicin hydrochloride liposome . . . . . . . . . . . . . . . . . . . . . . . . . . 31doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 24doxycycline hyclate caps . . . . . . . . . . 24doxycycline hyclate tabs 100mg, 20mg . . . . . . . . . . . . . . . . . . . . . 25doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . . . . . . 25doxycycline monohydrate tabs . . . . . 25doxycycline susr . . . . . . . . . . . . . . . . . . 25dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 28DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 31DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 56duloxetine hcl cpep 20mg . . . . . . . . . . 27duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 27duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 27DURAMORPH . . . . . . . . . . . . . . . . . . . . 19DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 60dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 51dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 51

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 28EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 42EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 42ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 50EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 37efavirenz caps 50mg . . . . . . . . . . . . . . . 37efavirenz caps 200mg . . . . . . . . . . . . . 37efavirenz tabs . . . . . . . . . . . . . . . . . . . . 37ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 51ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 56ELIGARD INJ 22.5MG . . . . . . . . . . . . . 56ELIGARD INJ 30MG . . . . . . . . . . . . . . . 56ELIGARD INJ 45MG . . . . . . . . . . . . . . . 56

72


Covered Drugs Index

FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 22flac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 51flecainide acetate . . . . . . . . . . . . . . . . . . 43FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 61FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 61FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 61FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 61FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 61fluconazole in nacl . . . . . . . . . . . . . . . . . 28fluconazole susr . . . . . . . . . . . . . . . . . . 29fluconazole tabs . . . . . . . . . . . . . . . . . . 29flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 29fludarabine phosphate inj 50mg . . . . 32fludrocortisone acetate . . . . . . . . . . . . . 52flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 61fluocinolone acetonide . . . . . . . . . . . . . 52fluocinolone acetonide . . . . . . . . . . . . . 61fluocinolone acetonide body . . . . . . . . 52fluocinolone acetonide ear drops . . . 61fluocinolone acetonide scalp . . . . . . . 52fluocinonide crea 0.1% . . . . . . . . . . . . . 52fluocinonide crea 0.05% . . . . . . . . . . . 52fluocinonide external soln . . . . . . . . . . 52fluocinonide gel . . . . . . . . . . . . . . . . . . . 52fluocinonide oint . . . . . . . . . . . . . . . . . . 52fluoride chew 0.25mg . . . . . . . . . . . . . . 48fluoritab chew 0.5mg, 1mg . . . . . . . . . 48fluorometholone . . . . . . . . . . . . . . . . . . . 60fluorouracil crea 0.5% . . . . . . . . . . . . . . 47fluorouracil crea 5% . . . . . . . . . . . . . . . 47fluorouracil external soln . . . . . . . . . . . 47fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 31fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 27fluoxetine hcl caps 20mg . . . . . . . . . . . 27fluoxetine hcl caps 40mg . . . . . . . . . . . 27

FANAPT TABS 1MG, 2MG, 4MG . . . 36FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . . . . . . . . 36FANAPT TITRATION PACK . . . . . . . . 36FARESTON . . . . . . . . . . . . . . . . . . . . . . . 30FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 39FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 33FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 30febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 29felbamate susp . . . . . . . . . . . . . . . . . . . 26felbamate tabs . . . . . . . . . . . . . . . . . . . . 26felodipine er . . . . . . . . . . . . . . . . . . . . . . . 44femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 54fenofibrate caps 43mg, 50mg . . . . . . . 45fenofibrate caps 67mg . . . . . . . . . . . . . 45fenofibrate caps 130mg, 150mg . . . . 45fenofibrate caps 134mg, 200mg . . . . 45fenofibrate micronized caps 67mg . . 45fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 45fenofibrate tabs 48mg, 54mg . . . . . . . 45fenofibrate tabs 145mg, 160mg . . . . . 45fenofibric acid dr cpdr 45mg . . . . . . . . 45fenofibric acid dr cpdr 135mg . . . . . . . 45fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 19fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 20fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 20fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 20FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 49FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 59FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 27FETZIMA TITRATION PACK . . . . . . . 27finasteride tabs 5mg . . . . . . . . . . . . . . . 52FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 57FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 59FIRMAGON INJ 80MG . . . . . . . . . . . . . 56FIRMAGON INJ 120MG . . . . . . . . . . . 56

escitalopram oxalate oral soln . . . . . 27escitalopram oxalate tabs 5mg . . . . . 27escitalopram oxalate tabs 10mg . . . . 27escitalopram oxalate tabs 20mg . . . . 27esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 19esomeprazole magnesium . . . . . . . . . 51estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 54estradiol crea . . . . . . . . . . . . . . . . . . . . . 54estradiol pttw . . . . . . . . . . . . . . . . . . . . . 54estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 54estradiol tabs 0.5mg, 1mg, 2mg . . . . 54estradiol tabs 10mcg . . . . . . . . . . . . . . . 54estradiol valerate . . . . . . . . . . . . . . . . . . 54ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 54ethacrynate sodium . . . . . . . . . . . . . . . . 45ethambutol hcl . . . . . . . . . . . . . . . . . . . . 30ethambutol hydrochloride . . . . . . . . . . 30ethosuximide . . . . . . . . . . . . . . . . . . . . . . 25ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 54ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 32etidronate disodium . . . . . . . . . . . . . . . . 59etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 19etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 19etoposide inj . . . . . . . . . . . . . . . . . . . . . . 33EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 30EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 38exemestane . . . . . . . . . . . . . . . . . . . . . . . 32EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . 49ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 45ezetimibe/simvastatin . . . . . . . . . . . . . . 45

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 51falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 38famotidine inj . . . . . . . . . . . . . . . . . . . . . 50famotidine premixed . . . . . . . . . . . . . . . 50famotidine tabs 20mg, 40mg . . . . . . . 50

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Covered Drugs Index

gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 51gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 51gavilyte-n/flavor pack . . . . . . . . . . . . . . 51GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 34gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 31gemcitabine hcl . . . . . . . . . . . . . . . . . . . . 31gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 31gemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml . . . . . . . . . . . . . . . . . . . . . . . 31gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 45generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 51gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 57GENOTROPIN . . . . . . . . . . . . . . . . . . . . 53GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 53GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 53gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 21gentamicin sulfate crea . . . . . . . . . . . . 21gentamicin sulfate inj . . . . . . . . . . . . . . 21gentamicin sulfate oint . . . . . . . . . . . . 21gentamicin sulfate ophthalmic soln . . 21gentamicin sulfate pediatric . . . . . . . . 21GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 37GEODON INJ . . . . . . . . . . . . . . . . . . . . 36GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 47GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 33GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 30glimepiride tabs 1mg . . . . . . . . . . . . . . . 39glimepiride tabs 2mg . . . . . . . . . . . . . . . 39glimepiride tabs 4mg . . . . . . . . . . . . . . . 39glipizide er tb24 2.5mg . . . . . . . . . . . . . 39glipizide er tb24 5mg . . . . . . . . . . . . . . . 39glipizide er tb24 10mg . . . . . . . . . . . . . 39glipizide/metformin hydrochloride tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . 39

FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 48fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 30furosemide inj . . . . . . . . . . . . . . . . . . . . 45furosemide oral soln . . . . . . . . . . . . . . 45furosemide tabs . . . . . . . . . . . . . . . . . . . 45FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 32FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 38fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 54FYCOMPA SUSP . . . . . . . . . . . . . . . . . 25FYCOMPA TABS . . . . . . . . . . . . . . . . . 25

Ggabapentin caps 100mg . . . . . . . . . . . 26gabapentin caps 300mg, 400mg . . . . 26gabapentin oral soln . . . . . . . . . . . . . . 26gabapentin tabs 600mg . . . . . . . . . . . . 26gabapentin tabs 800mg . . . . . . . . . . . . 26GABITRIL TABS 12MG, 16MG . . . . . 26galantamine hydrobromide er . . . . . . 26galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 26galantamine hydrobromide tabs . . . . 26GAMMAKED INJ 1GM/10ML . . . . . . . 58GAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 58GAMUNEX-C INJ 1GM/10ML . . . . . . 58GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 58ganciclovir inj 500mg, 500mg/10ml . . 37GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 58GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 50

fluoxetine hydrochloride caps 10mg . . . . . . . . . . . . . . . . . . . . . . . . 27fluoxetine hydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 27fluoxetine hydrochloride tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 27fluoxetine hydrochloride tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 27fluphenazine decanoate . . . . . . . . . . . . 35fluphenazine hcl conc . . . . . . . . . . . . . 35fluphenazine hcl inj . . . . . . . . . . . . . . . . 35fluphenazine hcl tabs . . . . . . . . . . . . . . 35fluphenazine hydrochloride . . . . . . . . . 35flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 19flurbiprofen sodium . . . . . . . . . . . . . . . . 60flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 30fluticasone propionate crea . . . . . . . . 52fluticasone propionate oint . . . . . . . . . 52fluticasone propionate susp . . . . . . . . 61fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . 27fluvoxamine maleate tabs 100mg . . . . . . . . . . . . . . . . . . . . . . . 27FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 31fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 41fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 41fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 41fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 41FORTAMET . . . . . . . . . . . . . . . . . . . . . . . 39FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 59fosamprenavir calcium . . . . . . . . . . . . . 38fosinopril sodium . . . . . . . . . . . . . . . . . . 43fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 43fosphenytoin sodium . . . . . . . . . . . . . . . 26FREAMINE HBC 6.9% . . . . . . . . . . . . . 48

74


Covered Drugs Index

HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 57HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 40HUMULIN 70/30 KWIKPEN . . . . . . . . 40HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 40HUMULIN N KWIKPEN . . . . . . . . . . . . 40HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 40HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 40HUMULIN R U-500 KWIKPEN. . . . . . 40hydralazine hcl inj . . . . . . . . . . . . . . . . . 46hydralazine hcl tabs . . . . . . . . . . . . . . . 46hydralazine hydrochloride tabs 100mg, 25mg, 50mg . . . . . . . . . . . . . . . 46hydrochlorothiazide . . . . . . . . . . . . . . . . 45hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . . . . . . 20hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . 20hydrocodone bitartrate/ acetaminophen oral soln 325mg/15ml; 7.5mg/15ml . . . . . . . . . . 20hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg . . 20hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . . . . . . . . . 20hydrocodone/ibuprofen . . . . . . . . . . . . 20hydrocortisone/acetic acid . . . . . . . . . . 61hydrocortisone butyrate crea . . . . . . . 52hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 52hydrocortisone butyrate (lipid) . . . . . . 52hydrocortisone butyrate (lipophilic) . . 52hydrocortisone butyrate oint . . . . . . . 52hydrocortisone enem . . . . . . . . . . . . . . 59hydrocortisone external crea . . . . . . . 52hydrocortisone lotn 2.5% . . . . . . . . . . . 52hydrocortisone oint 1%, 2.5% . . . . . . 53hydrocortisone rectal crea . . . . . . . . . 53hydrocortisone tabs . . . . . . . . . . . . . . . 53hydrocortisone valerate . . . . . . . . . . . . 53

heparin sodium/nacl 0.9% . . . . . . . . . . 41heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 41heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 41heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9% . . . . . . . . . . . . . . 41heparin sodium/sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 41HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 48HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 58HERCEPTIN HYLECTA . . . . . . . . . . . . 34HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 46HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 58HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 40HUMALOG JUNIOR KWIKPEN . . . . 40HUMALOG KWIKPEN . . . . . . . . . . . . . 40HUMALOG MIX 50/50 . . . . . . . . . . . . . 40HUMALOG MIX 50/50 KWIKPEN . . . 40HUMALOG MIX 75/25 . . . . . . . . . . . . . 40HUMALOG MIX 75/25 KWIKPEN . . . 40HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 57HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 57HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK) . . . . . . . . . . . . . 57HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH) . . . . . . . . . . . . . . . . . 57HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 57HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 57HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 57HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 57

glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg . . . 39glipizide tabs 5mg . . . . . . . . . . . . . . . . . 39glipizide tabs 10mg . . . . . . . . . . . . . . . . 39glipizide xl tb24 2.5mg . . . . . . . . . . . . . 39glipizide xl tb24 5mg . . . . . . . . . . . . . . . 39glipizide xl tb24 10mg . . . . . . . . . . . . . . 39GLUCAGEN HYPOKIT . . . . . . . . . . . . 40GLUCAGON EMERGENCY KIT . . . . 40glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 50glycopyrrolate tabs 1mg, 2mg . . . . . . 50glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 39GRALISE . . . . . . . . . . . . . . . . . . . . . . . . . 26GRALISE STARTER . . . . . . . . . . . . . . . 26granisetron hcl inj 1mg/ml . . . . . . . . . . 28granisetron hcl tabs . . . . . . . . . . . . . . . 28granisetron hydrochloride . . . . . . . . . . 28griseofulvin microsize . . . . . . . . . . . . . . 29griseofulvin ultramicrosize . . . . . . . . . . 29GUANIDINE HCL . . . . . . . . . . . . . . . . . . 29

Hhailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 54HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 32halobetasol propionate crea . . . . . . . 52halobetasol propionate oint . . . . . . . . 52haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 35haloperidol decanoate . . . . . . . . . . . . . 35haloperidol lactate . . . . . . . . . . . . . . . . . 35HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 37HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 58heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 56heparin sodium/d5w . . . . . . . . . . . . . . . 41heparin sodium/dextrose . . . . . . . . . . . 41heparin sodium inj 5000unit/0.5ml . . 41heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml . . . . . . . . . . 41

75


Covered Drugs Index

INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 39IPOL INACTIVATED IPV . . . . . . . . . . . 58ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 62ipratropium bromide inhalation soln . . 62ipratropium bromide nasal soln . . . . 62irbesartan/hydrochlorothiazide . . . . . . 42irbesartan tabs 150mg, 75mg . . . . . . 42irbesartan tabs 300mg . . . . . . . . . . . . . 42IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 33irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 32irinotecan hydrochloride . . . . . . . . . . . . 32irinotecan hydrochloride . . . . . . . . . . . . 33irinotecan inj 100mg/5ml, 500mg/25ml . . . . . . . . . . . 32ISENTRESS CHEW 25MG . . . . . . . . . 37ISENTRESS CHEW 100MG . . . . . . . 37ISENTRESS HD . . . . . . . . . . . . . . . . . . . 37ISENTRESS PACK . . . . . . . . . . . . . . . 37ISENTRESS TABS . . . . . . . . . . . . . . . . 37isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 54isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 30isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 30isoniazid tabs . . . . . . . . . . . . . . . . . . . . . 30isosorbide dinitrate er . . . . . . . . . . . . . . 46isosorbide dinitrate tabs . . . . . . . . . . . 46isosorbide mononitrate . . . . . . . . . . . . . 46isosorbide mononitrate er . . . . . . . . . . 46isotonic gentamicin . . . . . . . . . . . . . . . . 21isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 47isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 44ISTODAX (OVERFILL) . . . . . . . . . . . . . 32itraconazole caps . . . . . . . . . . . . . . . . . 29itraconazole oral soln . . . . . . . . . . . . . . 29ivermectin tabs . . . . . . . . . . . . . . . . . . . 34IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 50JADENU SPRINKLE . . . . . . . . . . . . . . . 50

imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 47IMOVAX RABIES (H.D.C.V.) . . . . . . . 58incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 56INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 53INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 61indapamide . . . . . . . . . . . . . . . . . . . . . . . 45INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 58INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 31INFUMORPH 200 . . . . . . . . . . . . . . . . . 19INFUMORPH 500 . . . . . . . . . . . . . . . . . 19INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 33INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 32INTELENCE TABS 25MG . . . . . . . . . . 37INTELENCE TABS 100MG, 200MG . . 37INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 59INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU . . . . 37INTRON A INJ 6000000UNIT/ML . . . 37introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 54INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 23INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 36INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 36INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 36INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 36INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 36INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 60INVIRASE . . . . . . . . . . . . . . . . . . . . . . . . 38INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 39INVOKAMET XR . . . . . . . . . . . . . . . . . . 39

hydromorphone hcl dosette . . . . . . . . 20hydromorphone hcl inj . . . . . . . . . . . . . 20hydromorphone hcl liqd . . . . . . . . . . . 20hydromorphone hcl tabs 2mg, 4mg . 20hydromorphone hcl tabs 8mg . . . . . . . 20hydroxychloroquine sulfate . . . . . . . . . 34hydroxyprogesterone caproate . . . . . 56hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 31hyoscyamine sulfate elix . . . . . . . . . . . 50hyoscyamine sulfate subl . . . . . . . . . . 50hyoscyamine sulfate tabs . . . . . . . . . . 50hyoscyamine sulfate tbdp . . . . . . . . . . 50

Iibandronate sodium tabs . . . . . . . . . . 59IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 33ibuprofen susp . . . . . . . . . . . . . . . . . . . . 19ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 19ibu tabs 600mg, 800mg . . . . . . . . . . . . 19icatibant acetate . . . . . . . . . . . . . . . . . . . 57ICLUSIG TABS 15MG . . . . . . . . . . . . . 33ICLUSIG TABS 45MG . . . . . . . . . . . . . 33idarubicin hcl inj 10mg/10ml . . . . . . . . 32idarubicin hydrochloride inj 10mg/10ml . . . . . . . . . . . . . . . . . . . . . 32IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 30ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 60imatinib mesylate . . . . . . . . . . . . . . . . . . 33IMBRUVICA CAPS 70MG . . . . . . . . . . 33IMBRUVICA CAPS 140MG. . . . . . . . . 33IMBRUVICA TABS . . . . . . . . . . . . . . . . 33IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 34imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 23imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 23imipramine hcl tabs 25mg, 50mg . . . 28imipramine hydrochloride . . . . . . . . . . 28

76


Covered Drugs Index

lamotrigine odt . . . . . . . . . . . . . . . . . . . . 26LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 40LANTUS SOLOSTAR . . . . . . . . . . . . . . 40larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 54larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 54larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 54larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 54larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 32latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 60LATUDA TABS 80MG . . . . . . . . . . . . . . 36LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 36leflunomide . . . . . . . . . . . . . . . . . . . . . . . 58LENVIMA 4 MG DAILY DOSE . . . . . . 33LENVIMA 8 MG DAILY DOSE . . . . . . 33LENVIMA 10 MG DAILY DOSE . . . . . 33LENVIMA 12MG DAILY DOSE . . . . . 33LENVIMA 14 MG DAILY DOSE . . . . . 33LENVIMA 18 MG DAILY DOSE . . . . . 33LENVIMA 20 MG DAILY DOSE . . . . . 33LENVIMA 24 MG DAILY DOSE . . . . . 33lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 62letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 32leucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg . . . . . . . . 32leucovorin calcium tabs 5mg . . . . . . . 32leucovorin calcium tabs 10mg, 15mg, 25mg . . . . . . . . . . . . . . . . 32LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 30leuprolide acetate . . . . . . . . . . . . . . . . . 56levalbuterol tartrate hfa . . . . . . . . . . . . 62LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 40LEVEMIR FLEXTOUCH . . . . . . . . . . . 40levetiracetam er tb24 500mg . . . . . . . 25levetiracetam er tb24 750mg . . . . . . . 25levetiracetam inj . . . . . . . . . . . . . . . . . . 25levetiracetam oral soln . . . . . . . . . . . . 25

kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 54ketoconazole crea . . . . . . . . . . . . . . . . 29ketoconazole sham . . . . . . . . . . . . . . . 29ketoconazole tabs . . . . . . . . . . . . . . . . . 29ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 60KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 34KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 58kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 32KISQALI FEMARA 200 DOSE . . . . . . 30KISQALI FEMARA 400 DOSE . . . . . . 30KISQALI FEMARA 600 DOSE . . . . . . 30klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 49KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 49klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 49klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 49klor-con sprinkle . . . . . . . . . . . . . . . . . . . 49KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 59kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 51KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 33

Llabetalol hydrochloride inj 5mg/ml . . 43labetalol hydrochloride tabs . . . . . . . . 43LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 49LACTATED RINGERS IRRIGATION . . 59LACTATED RINGERS VIAFLEX . . . . 49lactulose oral soln . . . . . . . . . . . . . . . . . 51lamivudine oral soln . . . . . . . . . . . . . . . 38lamivudine tabs 100mg . . . . . . . . . . . . 37lamivudine tabs 150mg . . . . . . . . . . . . 38lamivudine tabs 300mg . . . . . . . . . . . . 38lamivudine/zidovudine . . . . . . . . . . . . . 38lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 26lamotrigine er . . . . . . . . . . . . . . . . . . . . . 26

JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 33jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 41JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 39JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 40JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 39JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 40JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 40jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 56JENTADUETO . . . . . . . . . . . . . . . . . . . . 40JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 40JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 40JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 32jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 37junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 54junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 54junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 54junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 54

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 48KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 34KALETRA TABS 100MG; 25MG . . . . 38KALETRA TABS 200MG; 50MG . . . . 38KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 62KANJINTI INJ 420MG . . . . . . . . . . . . . 34kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KCL 0.3%/D5W/NACL 0.9% . . . . . . . . 48KCL 0.3%/D5W/NACL 0.45% . . . . . . 48KCL 0.15%/D5W/NACL 0.2% . . . . . . 48KCL 0.15%/D5W/NACL 0.9% . . . . . . 48KCL 0.15%/D5W/NACL 0.45% . . . . . 48KCL 0.15%/D5W/NACL 0.225% . . . . 48KCL 0.075%/D5W/NACL 0.45% . . . . 48kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 54

77


Covered Drugs Index

losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 42LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 60LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 60lovastatin tabs 10mg, 20mg . . . . . . . . 45lovastatin tabs 40mg . . . . . . . . . . . . . . . 45low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 55loxapine . . . . . . . . . . . . . . . . . . . . . . . . . . 35loxapine succinate . . . . . . . . . . . . . . . . . 35ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 60LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 51LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 34LUPRON DEPOT (1-MONTH) . . . . . . 56LUPRON DEPOT (3-MONTH) . . . . . . 56LUPRON DEPOT (4-MONTH) . . . . . . 56LUPRON DEPOT (6-MONTH) . . . . . . 56LUPRON DEPOT-PED (1-MONTH) . . 56LUPRON DEPOT-PED (3-MONTH) . . 56lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55LYNPARZA . . . . . . . . . . . . . . . . . . . . . . . 32LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 25LYRICA CAPS 225MG, 300MG . . . . . 25LYRICA CR TB24 165MG, 82.5MG . . 47LYRICA CR TB24 330MG . . . . . . . . . . 47LYRICA ORAL SOLN . . . . . . . . . . . . . . 25LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 56lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Mmagnesium sulfate in d5w . . . . . . . . . . 25MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML . . . . . . . . . . . . . . . . . . . . . . . . 49magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 49

lidocaine/prilocaine crea . . . . . . . . . . . 21lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 21lidocaine viscous . . . . . . . . . . . . . . . . . . 21lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 22lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 22linezolid susr . . . . . . . . . . . . . . . . . . . . . 22linezolid tabs . . . . . . . . . . . . . . . . . . . . . 22LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 51liothyronine sodium inj . . . . . . . . . . . . . 56liothyronine sodium tabs . . . . . . . . . . . 56LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 59lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 43lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 43lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 43lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 39lithium carbonate caps 300mg . . . . . . 39lithium carbonate er . . . . . . . . . . . . . . . . 39lithium carbonate tabs . . . . . . . . . . . . . 39LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 45LONSURF TABS 6.14MG; 15MG . . . 31LONSURF TABS 8.19MG; 20MG . . . 31loperamide hcl caps . . . . . . . . . . . . . . . 50lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 38lorazepam conc . . . . . . . . . . . . . . . . . . . 39lorazepam inj 2mg/ml, 4mg/ml . . . . . . 39lorazepam intensol . . . . . . . . . . . . . . . . 39lorazepam tabs 0.5mg, 1mg . . . . . . . . 39lorazepam tabs 2mg . . . . . . . . . . . . . . . 39LORBRENA TABS 25MG . . . . . . . . . . 32LORBRENA TABS 100MG . . . . . . . . . 32lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 20lorcet plus tabs 325mg; 7.5mg . . . . . . 20losartan potassium . . . . . . . . . . . . . . . . 42losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 42

levetiracetam/sodium chloride . . . . . . 25levetiracetam tabs . . . . . . . . . . . . . . . . 25levobunolol hcl . . . . . . . . . . . . . . . . . . . . 61levocarnitine . . . . . . . . . . . . . . . . . . . . . . 59levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 61levocetirizine dihydrochloride tabs . . 61levofloxacin in d5w . . . . . . . . . . . . . . . . 24levofloxacin inj . . . . . . . . . . . . . . . . . . . . 24levofloxacin oral soln . . . . . . . . . . . . . . 24levofloxacin tabs 250mg, 750mg . . . . 24levofloxacin tabs 500mg . . . . . . . . . . . 24levoleucovorin . . . . . . . . . . . . . . . . . . . . . 32levoleucovorin calcium . . . . . . . . . . . . . 32levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 54levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 54levonorgestrel/ethinyl estradiol tabs 0; 0, 20mcg; 0.1mg . . . . . . . . . . . 55levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg . . . . . . . . . . . . . . 55levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 55levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 55levothyroxine sodium tabs . . . . . . . . . 56levoxyl tabs 100mcg, 112mcg, 175mcg . . . . . . . . . 56LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG . . 56LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 38LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 34lidocaine hcl external soln . . . . . . . . . 20lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% . . . . . . . . . . . 20lidocaine hcl inj 100mg/5ml, 50mg/5ml . . . . . . . . . . . . . 43lidocaine hcl jelly gel . . . . . . . . . . . . . . 20lidocaine hcl mouth/throat soln . . . . . 20lidocaine hcl prsy . . . . . . . . . . . . . . . . . 21lidocaine hcl viscous . . . . . . . . . . . . . . . 21lidocaine oint . . . . . . . . . . . . . . . . . . . . . 21

78


Covered Drugs Index

methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 46methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 46methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 46methylprednisolone acetate inj 80mg/ml . . . . . . . . . . . . . . . . . . . . . . . 53methylprednisolone dose pack . . . . . 53methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 53methylprednisolone tabs . . . . . . . . . . . 53metoclopramide hcl inj . . . . . . . . . . . . 50metoclopramide hcl oral soln . . . . . . 50metoclopramide hcl tabs . . . . . . . . . . . 50metoclopramide hydrochloride . . . . . . 50metolazone . . . . . . . . . . . . . . . . . . . . . . . 45metoprolol/hydrochlorothiazide . . . . . 43metoprolol succinate er . . . . . . . . . . . . 43metoprolol tartrate inj . . . . . . . . . . . . . . 43metoprolol tartrate tabs . . . . . . . . . . . . 43metronidazole crea . . . . . . . . . . . . . . . . 22metronidazole gel . . . . . . . . . . . . . . . . . 22metronidazole inj 500mg/100ml; 0.79% . . . . . . . . . . . . . . 22metronidazole in nacl 0.79% . . . . . . . 22metronidazole lotn . . . . . . . . . . . . . . . . 22metronidazole tabs . . . . . . . . . . . . . . . . 22metronidazole vaginal . . . . . . . . . . . . . . 22mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 43MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 59mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 55microgestin 1.5/30 . . . . . . . . . . . . . . . . . 55microgestin 1/20 . . . . . . . . . . . . . . . . . . . 55microgestin fe . . . . . . . . . . . . . . . . . . . . . 55microgestin fe 1.5/30 . . . . . . . . . . . . . . 55midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 42miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 51mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 46MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 55

metaproterenol sulfate . . . . . . . . . . . . . 62metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 40metformin hcl er tb24 500mg (generic for Glumetza) . . . . . . . . . . . . . 40metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 40metformin hcl er tb24 1000mg, 500mg (generic for Fortamet) . . . . . . 40metformin hcl er tb24 1000mg (generic for Glumetza) . . . . . . . . . . . . . 40metformin hydrochloride oral soln . . . 40metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 40metformin hydrochloride tabs 850mg . . . . . . . . . . . . . . . . . . . . . . . 40metformin hydrochloride tabs 1000mg . . . . . . . . . . . . . . . . . . . . . . 40methadone hcl conc . . . . . . . . . . . . . . . 19methadone hcl inj . . . . . . . . . . . . . . . . . 19methadone hcl intensol . . . . . . . . . . . . 19methadone hcl oral soln 5mg/5ml . . . 19methadone hcl oral soln 10mg/5ml . . 19methadone hcl tabs 5mg . . . . . . . . . . . 19methadone hcl tabs 10mg . . . . . . . . . . 19methazolamide . . . . . . . . . . . . . . . . . . . . 45methenamine hippurate . . . . . . . . . . . . 22methimazole . . . . . . . . . . . . . . . . . . . . . . 57methocarbamol tabs . . . . . . . . . . . . . . 63methotrexate sodium . . . . . . . . . . . . . . 57methotrexate tabs . . . . . . . . . . . . . . . . . 57methoxsalen . . . . . . . . . . . . . . . . . . . . . . 47methscopolamine bromide . . . . . . . . . 50methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 46methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 46methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 46methylphenidate hydrochloride er tbcr 10mg . . . . . . . . . . . . . . . . . . . . . . 46

MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 56MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 56malathion . . . . . . . . . . . . . . . . . . . . . . . . . 35maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 27marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 55MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 27MATULANE . . . . . . . . . . . . . . . . . . . . . . . 30matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 44meclizine hcl tabs . . . . . . . . . . . . . . . . . 28MEDROL TABS 2MG . . . . . . . . . . . . . . 53medroxyprogesterone acetate inj . . . 56medroxyprogesterone acetate tabs . . 56mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 34megestrol acetate susp 40mg/ml . . . 56megestrol acetate tabs 20mg . . . . . . . 56megestrol acetate tabs 40mg . . . . . . . 56MEKINIST TABS 0.5MG . . . . . . . . . . . 33MEKINIST TABS 2MG . . . . . . . . . . . . . 33MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 32melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 55meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 19melphalan hydrochloride . . . . . . . . . . . 30memantine hcl tabs 5mg . . . . . . . . . . . 27memantine hcl tabs 10mg . . . . . . . . . . 26memantine hcl titration pak . . . . . . . . . 27memantine hydrochloride er . . . . . . . . 27memantine hydrochloride oral soln . . 27MENACTRA . . . . . . . . . . . . . . . . . . . . . . 58MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 55MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 55MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 58mercaptopurine . . . . . . . . . . . . . . . . . . . . 31meropenem . . . . . . . . . . . . . . . . . . . . . . . 23meropenem/sodium chloride . . . . . . . 23mesalamine dr tbec 1.2gm . . . . . . . . . 58mesalamine enem . . . . . . . . . . . . . . . . 59mesalamine kit . . . . . . . . . . . . . . . . . . . . 59mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32MESNEX TABS . . . . . . . . . . . . . . . . . . . 32metadate er . . . . . . . . . . . . . . . . . . . . . . . 46

79


Covered Drugs Index

naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 21NAMZARIC C4PK . . . . . . . . . . . . . . . . 47NAMZARIC CP24 . . . . . . . . . . . . . . . . . 47naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 19naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 19naproxen susp . . . . . . . . . . . . . . . . . . . . 19naproxen tabs 250mg . . . . . . . . . . . . . . 19naproxen tabs 375mg, 500mg . . . . . . 19naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 29NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 21NASONEX . . . . . . . . . . . . . . . . . . . . . . . . 61NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 29nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 40NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 59NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 25NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 34necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 55nefazodone hcl . . . . . . . . . . . . . . . . . . . . 27nefazodone hydrochloride . . . . . . . . . . 27neomycin/bacitracin/polymyxin . . . . . 22neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 22neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 60neomycin/polymyxin/gramicidin . . . . . 22neomycin/polymyxin/hc . . . . . . . . . . . . 61neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 22neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 61neomycin sulfate . . . . . . . . . . . . . . . . . . 21neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 22neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 22NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 49NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 32NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 35nevirapine er tb24 100mg . . . . . . . . . . 37nevirapine er tb24 400mg . . . . . . . . . . 37nevirapine susp . . . . . . . . . . . . . . . . . . . 37nevirapine tabs . . . . . . . . . . . . . . . . . . . 37

morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 20morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 20morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 20MORPHINE SULFATE TABS . . . . . . 20MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 51moxifloxacin hcl . . . . . . . . . . . . . . . . . . . 24moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 24moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 24moxifloxacin hydrochloride tabs . . . . 24MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 41MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 43multivitamin with fluoride chew . . . . . 50mupirocin crea . . . . . . . . . . . . . . . . . . . . 22mupirocin oint . . . . . . . . . . . . . . . . . . . . 22MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34mycophenolate mofetil caps . . . . . . . 57mycophenolate mofetil inj . . . . . . . . . . 57mycophenolate mofetil susr . . . . . . . . 57mycophenolate mofetil tabs . . . . . . . . 57mycophenolic acid dr . . . . . . . . . . . . . . 57MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 34myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 47MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 51

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 19nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44nadolol/bendroflumethiazide . . . . . . . . 44nafcillin sodium . . . . . . . . . . . . . . . . . . . . 23naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 29naftifine hydrochloride crea . . . . . . . . 29NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 51nalbuphine hcl inj 10mg/ml . . . . . . . . . 20nalbuphine hcl inj 20mg/ml . . . . . . . . . 20naloxone hcl . . . . . . . . . . . . . . . . . . . . . . 21

minocycline hcl caps . . . . . . . . . . . . . . 25minocycline hcl tabs . . . . . . . . . . . . . . . 25minocycline hydrochloride caps 100mg, 50mg . . . . . . . . . . . . . . . . 25minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 46mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 27mirtazapine odt . . . . . . . . . . . . . . . . . . . . 27misoprostol . . . . . . . . . . . . . . . . . . . . . . . 51MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 29mitigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19mitomycin inj 20mg, 5mg . . . . . . . . . . . 32mitomycin inj 40mg . . . . . . . . . . . . . . . . 32mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 32M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 58moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 43molindone hydrochloride . . . . . . . . . . . 35mometasone furoate crea . . . . . . . . . 53mometasone furoate external soln . . 53mometasone furoate oint . . . . . . . . . . 53mometasone furoate susp . . . . . . . . . 61mondoxyne nl caps 75mg . . . . . . . . . . 25mondoxyne nl caps 100mg . . . . . . . . . 25mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 55montelukast sodium chew . . . . . . . . . 61montelukast sodium pack . . . . . . . . . . 61montelukast sodium tabs . . . . . . . . . . 61morgidox 1x50mg . . . . . . . . . . . . . . . . . 25morgidox 1x100mg caps . . . . . . . . . . 25morgidox 2x100mg caps . . . . . . . . . . 25morphine sulfate er tbcr . . . . . . . . . . . 19morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 20morphine sulfate inj 1mg/ml . . . . . . . . 20MORPHINE SULFATE INJ 2MG/ML . . 20MORPHINE SULFATE INJ 4MG/ML . . 20MORPHINE SULFATE INJ 8MG/ML . . 20MORPHINE SULFATE INJ 10MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 20MORPHINE SULFATE INJ 50MG/ML, 5MG/ML . . . . . . . . . . . . . . . . 20

80


Covered Drugs Index

nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Ooctreotide acetate . . . . . . . . . . . . . . . . . 56ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 37ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 32OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62ofloxacin ophthalmic soln . . . . . . . . . . 24ofloxacin otic soln . . . . . . . . . . . . . . . . . 24ofloxacin tabs . . . . . . . . . . . . . . . . . . . . . 24ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 55olanzapine/fluoxetine . . . . . . . . . . . . . . 27olanzapine inj . . . . . . . . . . . . . . . . . . . . . 36olanzapine odt . . . . . . . . . . . . . . . . . . . . 36olanzapine tabs . . . . . . . . . . . . . . . . . . . 36olmesartan medoxomil . . . . . . . . . . . . . 42olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 42olopatadine hcl ophthalmic soln . . . . 60olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 60omega-3-acid ethyl esters . . . . . . . . . . 45omeprazole cpdr . . . . . . . . . . . . . . . . . . 51OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 60OMNIPOD DASH 5 PACK. . . . . . . . . . 60OMNIPOD STARTER KIT . . . . . . . . . . 60ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 32ondansetron hcl oral soln . . . . . . . . . . 28ondansetron hcl tabs . . . . . . . . . . . . . . 28ondansetron hydrochloride inj . . . . . . 28ondansetron hydrochloride tabs . . . . 28ondansetron odt . . . . . . . . . . . . . . . . . . . 28ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 26ONFI TABS 10MG, 20MG . . . . . . . . . . 26OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 34OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 62oralone dental paste . . . . . . . . . . . . . . . 47ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 51ORKAMBI PACK . . . . . . . . . . . . . . . . . . 62ORKAMBI TABS . . . . . . . . . . . . . . . . . . 62

norgestimate/ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 55norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg . . . . . . . . . . . . . . . 55norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 56NORMOSOL-M IN D5W . . . . . . . . . . . 49NORMOSOL -R . . . . . . . . . . . . . . . . . . . 49NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 49NORMOSOL-R IN D5W. . . . . . . . . . . . 49NORTHERA CAPS 100MG . . . . . . . . 44NORTHERA CAPS 200MG, 300MG . . 44nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 55nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 55nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 55nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 28nortriptyline hydrochloride . . . . . . . . . . 28NORVIR ORAL SOLN . . . . . . . . . . . . . 38NORVIR PACK . . . . . . . . . . . . . . . . . . . 38NOVOFINE 31 . . . . . . . . . . . . . . . . . . . . 59NOVOFINE 32GX6MM . . . . . . . . . . . . 59NOVOFINE AUTOCOVER 30GX8MM . . . . . . . . . . . . . . . . . . . . . . . . 59NOVOTWIST 32GX5MM . . . . . . . . . . . 59NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 29NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 29NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 30NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 47nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 57NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 36NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 59NUZYRA INJ . . . . . . . . . . . . . . . . . . . . . 25NUZYRA TABS . . . . . . . . . . . . . . . . . . . 25nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 29nystatin crea . . . . . . . . . . . . . . . . . . . . . . 29nystatin oint . . . . . . . . . . . . . . . . . . . . . . 29nystatin powd . . . . . . . . . . . . . . . . . . . . . 29nystatin susp . . . . . . . . . . . . . . . . . . . . . 29nystatin tabs . . . . . . . . . . . . . . . . . . . . . . 29nystatin/triamcinolone . . . . . . . . . . . . . . 29

NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 33niacin er tbcr 500mg . . . . . . . . . . . . . . . 45niacin er tbcr 1000mg, 750mg . . . . . . 45niacin tabs 500mg . . . . . . . . . . . . . . . . . 45niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45NIASPAN TBCR 500MG . . . . . . . . . . . 45NIASPAN TBCR 1000MG, 750MG . . 45nicardipine hcl . . . . . . . . . . . . . . . . . . . . . 44NICOTROL INHALER. . . . . . . . . . . . . . 21NICOTROL NS . . . . . . . . . . . . . . . . . . . . 21nifedipine er tb24 30mg, 60mg . . . . . 44nifedipine er tb24 90mg . . . . . . . . . . . . 44nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 30nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 44NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 32NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 31NITISINONE CAPS 2MG . . . . . . . . . . 51nitisinone caps 10mg, 5mg . . . . . . . . . 51nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 22nitrofurantoin macrocrystals caps 25mg . . . . . . . . . . . . . . . . . . . . . . . . 22nitrofurantoin macrocrystals caps 100mg, 50mg . . . . . . . . . . . . . . . . 22nitrofurantoin monohydrate . . . . . . . . . 22nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 22nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 46nitroglycerin lingual . . . . . . . . . . . . . . . . 46nitroglycerin subl . . . . . . . . . . . . . . . . . . 46nitroglycerin transdermal . . . . . . . . . . . 46nizatidine caps . . . . . . . . . . . . . . . . . . . . 50nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 56norethindrone . . . . . . . . . . . . . . . . . . . . . 56norethindrone acetate . . . . . . . . . . . . . . 56norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 55norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 55norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 55

81


Covered Drugs Index

PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 36pfizerpen inj 20000000unit, 5000000unit . . . . . . . . 23phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 28phenazopyridine hydrochloride . . . . . 52phenazopyridine hydrocholride . . . . . 52phenelzine sulfate . . . . . . . . . . . . . . . . . 27phenobarbital elix . . . . . . . . . . . . . . . . . 26phenobarbital tabs . . . . . . . . . . . . . . . . 26phenoxybenzamine hydrochloride . . 42phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 26phenytoin infatabs . . . . . . . . . . . . . . . . . 26phenytoin sodium . . . . . . . . . . . . . . . . . . 26phenytoin sodium extended . . . . . . . . 26philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 50PHOSPHOLINE IODIDE . . . . . . . . . . . 61PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 60physiosol irrigation . . . . . . . . . . . . . . . . . 60PICATO GEL 0.05% . . . . . . . . . . . . . . . 47PICATO GEL 0.015% . . . . . . . . . . . . . . 47PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 37pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 47pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 61pilocarpine hydrochloride tabs 5mg . . 47pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 47pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 35pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 55pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 44pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 40pioglitazone hcl/metformin hcl . . . . . . 40pioglitazone hydrochloride tabs 15mg, 30mg . . . . . . . . . . . . . . . . . . 40piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm . . . . . . . . . . 23piperacillin/tazobactam . . . . . . . . . . . . . 23PIQRAY 200MG DAILY DOSE . . . . . . 32PIQRAY 250MG DAILY DOSE . . . . . . 32PIQRAY 300MG DAILY DOSE . . . . . . 32pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 55

paliperidone er tb24 6mg . . . . . . . . . . . 36pamidronate disodium . . . . . . . . . . . . . 59PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 34pantoprazole sodium inj . . . . . . . . . . . 51pantoprazole sodium tbec . . . . . . . . . 51paricalcitol caps 1mcg, 2mcg . . . . . . . 59paricalcitol caps 4mcg . . . . . . . . . . . . . 59paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47paromomycin sulfate . . . . . . . . . . . . . . . 21paroxetine hcl tabs 10mg . . . . . . . . . . 27paroxetine hcl tabs 30mg, 40mg . . . . 27paroxetine hydrochloride tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 27PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 30PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 28PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 60PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 58PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 58peg 3350/electrolytes . . . . . . . . . . . . . . 51peg-3350/electrolytes . . . . . . . . . . . . . . 51peg-3350/nacl/na bicarbonate/kcl . . . 51PEGANONE . . . . . . . . . . . . . . . . . . . . . . 26PEGASYS INJ 180MCG/0.5ML . . . . . 37PEGASYS INJ 180MCG/ML . . . . . . . . 37PEGASYS PROCLICK . . . . . . . . . . . . . 37penicillamine . . . . . . . . . . . . . . . . . . . . . . 50penicillin g potassium . . . . . . . . . . . . . . 23penicillin v potassium oral soln . . . . . 23penicillin v potassium tabs 250mg . . 23penicillin v potassium tabs 500mg . . 23PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 34pentamidine isethionate . . . . . . . . . . . . 34pentoxifylline er . . . . . . . . . . . . . . . . . . . . 44PERFOROMIST . . . . . . . . . . . . . . . . . . . 62PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 49perindopril erbumine . . . . . . . . . . . . . . . 43PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 34permethrin . . . . . . . . . . . . . . . . . . . . . . . . 35perphenazine . . . . . . . . . . . . . . . . . . . . . 35perphenazine/amitriptyline . . . . . . . . . 28

orphenadrine citrate er . . . . . . . . . . . . . 63orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 55oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 50oseltamivir phosphate caps . . . . . . . . 38oseltamivir phosphate susr . . . . . . . . 38OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 50oxacillin sodium . . . . . . . . . . . . . . . . . . . 23oxaliplatin inj 100mg . . . . . . . . . . . . . . . 32oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 32oxandrolone tabs 2.5mg . . . . . . . . . . . 53oxandrolone tabs 10mg . . . . . . . . . . . . 53oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 19oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 39oxcarbazepine susp . . . . . . . . . . . . . . . 26oxcarbazepine tabs . . . . . . . . . . . . . . . 26oxybutynin chloride er tb24 5mg . . . . 51oxybutynin chloride er tb24 10mg, 15mg . . . . . . . . . . . . . . . . . . . . . . . 51oxybutynin chloride syrp . . . . . . . . . . . 51oxybutynin chloride tabs . . . . . . . . . . . 51oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 20oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 20oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 20oxycodone/aspirin . . . . . . . . . . . . . . . . . 20oxycodone hcl conc . . . . . . . . . . . . . . . 20oxycodone hcl tabs . . . . . . . . . . . . . . . 20oxycodone hydrochloride oral soln . . 20oxycodone hydrochloride tabs . . . . . 20oxycodone/ibuprofen . . . . . . . . . . . . . . 20OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 40

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 43paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml . . . . . . . . . . 32paliperidone er tb24 1.5mg, 3mg, 9mg . . . . . . . . . . . . . . . . . . 36

82


Covered Drugs Index

PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 28PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 62PROAIR RESPICLICK . . . . . . . . . . . . . 62probenecid . . . . . . . . . . . . . . . . . . . . . . . . 29probenecid/colchicine . . . . . . . . . . . . . . 29PROCALAMINE . . . . . . . . . . . . . . . . . . . 49prochlorperazine . . . . . . . . . . . . . . . . . . 28prochlorperazine edisylate inj 10mg/2ml . . . . . . . . . . . . . . . . . . . . . . 35prochlorperazine maleate . . . . . . . . . . 35PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 41PROCRIT INJ 20000UNIT/ML . . . . . . 41PROCRIT INJ 40000UNIT/ML . . . . . . 41procto-med hc . . . . . . . . . . . . . . . . . . . . . 53procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 53proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 53proctozone-hc . . . . . . . . . . . . . . . . . . . . . 53progesterone caps . . . . . . . . . . . . . . . . 56PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 40PROGRAF INJ . . . . . . . . . . . . . . . . . . . 57PROGRAF PACK . . . . . . . . . . . . . . . . . 57PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 62PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 60PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 32PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 59PROMACTA PACK . . . . . . . . . . . . . . . . 41PROMACTA TABS . . . . . . . . . . . . . . . . 41promethazine hcl supp . . . . . . . . . . . . 28promethazine hcl syrp . . . . . . . . . . . . . 28promethazine hcl tabs 12.5mg . . . . . . 28promethazine hydrochloride tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . 28promethegan . . . . . . . . . . . . . . . . . . . . . . 28propafenone hcl . . . . . . . . . . . . . . . . . . . 43propafenone hydrochloride er . . . . . . 43propantheline bromide . . . . . . . . . . . . . 50proparacaine hcl . . . . . . . . . . . . . . . . . . . 60propranolol hcl er . . . . . . . . . . . . . . . . . . 44

prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 42pravastatin sodium . . . . . . . . . . . . . . . . 45praziquantel . . . . . . . . . . . . . . . . . . . . . . . 34prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 42prazosin hydrochloride caps 2mg . . . 42PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 60PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 60PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 60prednicarbate oint . . . . . . . . . . . . . . . . . 53prednisolone . . . . . . . . . . . . . . . . . . . . . . 53prednisolone acetate . . . . . . . . . . . . . . 60prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 60prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 53prednisone intensol . . . . . . . . . . . . . . . . 53prednisone oral soln . . . . . . . . . . . . . . 53prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 53prednisone tabs 50mg . . . . . . . . . . . . . 53prednisone tbpk . . . . . . . . . . . . . . . . . . . 53pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg . . . . . . . . 25pregabalin caps 225mg, 300mg . . . . 25pregabalin oral soln . . . . . . . . . . . . . . . 25PREMARIN CREA . . . . . . . . . . . . . . . . 55PREMARIN INJ . . . . . . . . . . . . . . . . . . . 55PREMARIN TABS . . . . . . . . . . . . . . . . 55PREMASOL . . . . . . . . . . . . . . . . . . . . . . . 49prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 45previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 55PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 38PREZISTA SUSP . . . . . . . . . . . . . . . . . 38PREZISTA TABS 75MG . . . . . . . . . . . . 38PREZISTA TABS 150MG . . . . . . . . . . . 38PREZISTA TABS 600MG . . . . . . . . . . . 38PREZISTA TABS 800MG . . . . . . . . . . . 38PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 30PRIMAQUINE PHOSPHATE . . . . . . . 34primidone . . . . . . . . . . . . . . . . . . . . . . . . . 26

pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 55PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 49podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 47polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22polymyxin b sulfate . . . . . . . . . . . . . . . . 22polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 22POMALYST . . . . . . . . . . . . . . . . . . . . . . . 30portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 55PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 32POSACONAZOLE DR . . . . . . . . . . . . . 29potassium chloride cr . . . . . . . . . . . . . . 49potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l . . . . . . . 49potassium chloride/dextrose/lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l . . . . . . . . 49POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L . . . . 49potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 49potassium chloride er cpcr . . . . . . . . . 49potassium chloride er tbcr . . . . . . . . . 49potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 49potassium chloride oral soln . . . . . . . 49potassium chloride pack . . . . . . . . . . . 49potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 49potassium chloride sr . . . . . . . . . . . . . . 49potassium citrate er . . . . . . . . . . . . . . . . 49POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 34PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 41PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 45pramipexole dihydrochloride . . . . . . . . 35pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 35pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 35

83


Covered Drugs Index

REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 36REYATAZ PACK . . . . . . . . . . . . . . . . . . 38RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 60ribavirin caps . . . . . . . . . . . . . . . . . . . . . 37ribavirin inhalation soln . . . . . . . . . . . . 62ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 37rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 30rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 30RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 30riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47rimantadine hcl . . . . . . . . . . . . . . . . . . . . 38ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l . . . . . . . . 49RINGERS IRRIGATION . . . . . . . . . . . . 60RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 58RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 40RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 36RISPERDAL CONSTA INJ 50MG . . . 36risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 36risperidone odt tbdp 4mg . . . . . . . . . . . 36risperidone oral soln . . . . . . . . . . . . . . 36risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 36risperidone tabs 4mg . . . . . . . . . . . . . . 36ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 38RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 34RITUXAN HYCELA . . . . . . . . . . . . . . . . 34rivastigmine tartrate . . . . . . . . . . . . . . . . 26rivastigmine transdermal system . . . . 26rizatriptan benzoate . . . . . . . . . . . . . . . . 29rizatriptan benzoate odt . . . . . . . . . . . . 29ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 61romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 32ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 35ropinirole hydrochloride tabs 0.25mg, 3mg . . . . . . . . . . . . . . . . . 35rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 22rosuvastatin calcium . . . . . . . . . . . . . . . 45ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 58

ranitidine hcl syrp . . . . . . . . . . . . . . . . . 50ranitidine hcl tabs 150mg, 300mg . . . 50ranitidine hydrochloride caps . . . . . . 50ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml . . . . . . . . . . . . . 50ranolazine er . . . . . . . . . . . . . . . . . . . . . . 44RAPAMUNE ORAL SOLN . . . . . . . . . 57rasagiline mesylate . . . . . . . . . . . . . . . . 35REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47REBIF REBIDOSE . . . . . . . . . . . . . . . . 47REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 47REBIF TITRATION PACK . . . . . . . . . . 47reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 55RECOMBIVAX HB . . . . . . . . . . . . . . . . . 58RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 48REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 29REGRANEX . . . . . . . . . . . . . . . . . . . . . . 48RELISTOR INJ 8MG/0.4ML . . . . . . . . 50RELISTOR INJ 12MG/0.6ML . . . . . . . 50REMODULIN . . . . . . . . . . . . . . . . . . . . . . 62RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 57RENVELA PACK . . . . . . . . . . . . . . . . . . 50RENVELA TABS . . . . . . . . . . . . . . . . . . 50repaglinide tabs 0.5mg, 1mg . . . . . . . 40repaglinide tabs 2mg . . . . . . . . . . . . . . 40REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 45REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 45REPATHA SURECLICK . . . . . . . . . . . . 45RESCRIPTOR . . . . . . . . . . . . . . . . . . . . 37RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 60RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 42RETACRIT INJ 40000UNIT/ML . . . . . 42RETROVIR IV INFUSION . . . . . . . . . . 38REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 30REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 30

propranolol hcl inj . . . . . . . . . . . . . . . . . 44propranolol hcl oral soln . . . . . . . . . . . 44propranolol hcl tabs 40mg, 80mg . . . 44propranolol hydrochloride er . . . . . . . . 44propranolol hydrochloride tabs 10mg, 20mg, 60mg . . . . . . . . . . . 44propranolol/hydrochlorothiazide . . . . 44propylthiouracil . . . . . . . . . . . . . . . . . . . . 57PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 58PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 49protriptyline hcl . . . . . . . . . . . . . . . . . . . . 28PULMOZYME . . . . . . . . . . . . . . . . . . . . . 62PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 31pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 30pyridostigmine bromide er . . . . . . . . . . 29pyridostigmine bromide tabs 60mg . . 29

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 58quetiapine fumarate . . . . . . . . . . . . . . . 36quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 36quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 36quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 43quinapril hydrochloride tabs 10mg . . 43quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 43quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 43quinidine sulfate . . . . . . . . . . . . . . . . . . . 43quinine sulfate . . . . . . . . . . . . . . . . . . . . . 34

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 58raloxifene hydrochloride . . . . . . . . . . . . 56ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 63ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 43RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 44ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 50

84


Covered Drugs Index

sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 43sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 43sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 43sotalol hydrochloride af . . . . . . . . . . . . 43sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 43sotalol hydrochloride tabs 120mg, 80mg . . . . . . . . . . . . . . . . . . . . . 43spironolactone . . . . . . . . . . . . . . . . . . . . 45spironolactone/hydrochlorothiazide . . 45SPORANOX ORAL SOLN . . . . . . . . . 29SPRAVATO 56MG DOSE . . . . . . . . . . 27SPRAVATO 84MG DOSE . . . . . . . . . . 27sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 55SPRITAM TB3D 750MG . . . . . . . . . . . 25SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 25SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 33sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 58stavudine caps 15mg, 20mg . . . . . . . . 38stavudine caps 30mg, 40mg . . . . . . . . 38sterile water irrigation . . . . . . . . . . . . . . 60sterile water irrigation plastic bottle . . 60sterile water irrigation w/hanger . . . . . 60STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 53STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 33streptomycin sulfate . . . . . . . . . . . . . . . 21STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 37SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 21sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 51sulfacetamide sodium lotn . . . . . . . . . 24sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 24sulfacetamide sodium/ prednisolone sodium phosphate . . . . 24sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 24sulfamethoxazole/trimethoprim ds . . 24sulfamethoxazole/trimethoprim inj . . 24

sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 56SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 58SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 56sildenafil citrate tabs 20mg . . . . . . . . . 62SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 63silver sulfadiazine . . . . . . . . . . . . . . . . . 22SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 61SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 58simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 45sirolimus oral soln . . . . . . . . . . . . . . . . . 57sirolimus tabs . . . . . . . . . . . . . . . . . . . . . 57SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 30SIVEXTRO TABS . . . . . . . . . . . . . . . . . 22SKYRIZI . . . . . . . . . . . . . . . . . . . . . . . . . . 57sodium bicarbonate inj . . . . . . . . . . . . 49sodium chloride 0.45% . . . . . . . . . . . . . 49sodium chloride inj 0.45%, 0.9%, 3%, 5% . . . . . . . . . . . . . . 49sodium chloride irrigation 0.9% . . . . . 60sodium fluoride chew 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 49SODIUM LACTATE INJ 5MEQ/ML . . 49sodium phenylbutyrate . . . . . . . . . . . . . 51sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 50sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 50sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 24solifenacin succinate . . . . . . . . . . . . . . . 51SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 40SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 30SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 53SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 56SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 56SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 56SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 56sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 58roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 25roweepra xr tb24 500mg . . . . . . . . . . . 25roweepra xr tb24 750mg . . . . . . . . . . . 25ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 63ROZLYTREK CAPS 100MG . . . . . . . . 32ROZLYTREK CAPS 200MG . . . . . . . . 32RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 32RUCONEST . . . . . . . . . . . . . . . . . . . . . . 57RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 32RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 35

SSABRIL TABS . . . . . . . . . . . . . . . . . . . . 26salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 19SAMSCA TABS 15MG . . . . . . . . . . . . . 50SAMSCA TABS 30MG . . . . . . . . . . . . . 50sancuso . . . . . . . . . . . . . . . . . . . . . . . . . . 28SANDIMMUNE ORAL SOLN . . . . . . 57SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 48SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 36scopolamine . . . . . . . . . . . . . . . . . . . . . . 28selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 35selenium sulfide lotn . . . . . . . . . . . . . . 48SELZENTRY ORAL SOLN . . . . . . . . 38SELZENTRY TABS 25MG . . . . . . . . . 38SELZENTRY TABS 150MG, 75MG . . 38SELZENTRY TABS 300MG . . . . . . . . 38SENSIPAR TABS 30MG, 60MG . . . . 59SENSIPAR TABS 90MG . . . . . . . . . . . 59SEREVENT DISKUS . . . . . . . . . . . . . . 62sertraline hcl conc . . . . . . . . . . . . . . . . . 28sertraline hcl tabs 25mg . . . . . . . . . . . . 28sertraline hcl tabs 50mg . . . . . . . . . . . . 28sertraline hydrochloride tabs 100mg . . . . . . . . . . . . . . . . . . . . . . . 28setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 55sevelamer carbonate pack . . . . . . . . . 50sevelamer carbonate tabs . . . . . . . . . 50

85


Covered Drugs Index

telmisartan tabs 80mg . . . . . . . . . . . . . 42temazepam caps 15mg, 30mg . . . . . 63temazepam caps 22.5mg, 7.5mg . . . 63temsirolimus . . . . . . . . . . . . . . . . . . . . . . 34TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 58tenofovir disoproxil fumarate . . . . . . . 38terazosin hcl caps 1mg, 5mg . . . . . . . 42terazosin hcl caps 10mg . . . . . . . . . . . 42terazosin hydrochloride . . . . . . . . . . . . 42terbinafine hcl tabs . . . . . . . . . . . . . . . . 29terbutaline sulfate . . . . . . . . . . . . . . . . . 62terconazole . . . . . . . . . . . . . . . . . . . . . . . 29testosterone cypionate . . . . . . . . . . . . . 53testosterone enanthate . . . . . . . . . . . . 53testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 54testosterone pump gel 1% . . . . . . . . . 54tetrabenazine tabs 12.5mg . . . . . . . . . 47tetrabenazine tabs 25mg . . . . . . . . . . . 47tetracycline hydrochloride . . . . . . . . . . 25TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 53THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 30THALOMID CAPS 200MG . . . . . . . . . 30THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 62theophylline er tb12 300mg . . . . . . . . 62theophylline er tb24 . . . . . . . . . . . . . . . 62thioridazine hcl . . . . . . . . . . . . . . . . . . . . 35thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 30thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 35THYMOGLOBULIN . . . . . . . . . . . . . . . . 58tiagabine hydrochloride . . . . . . . . . . . . 26TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 34tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 22timolol maleate ophthalmic gel forming . . . . . . . . . . . . . . . . . . . . . . . . 61timolol maleate ophthalmic soln . . . . 61timolol maleate tabs . . . . . . . . . . . . . . . 44TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 60TIVICAY TABS 10MG . . . . . . . . . . . . . . 37

TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 34TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 32tamoxifen citrate . . . . . . . . . . . . . . . . . . . 30tamsulosin hydrochloride . . . . . . . . . . . 52TARCEVA TABS 25MG . . . . . . . . . . . . 34TARCEVA TABS 100MG, 150MG . . . 34TARGRETIN GEL . . . . . . . . . . . . . . . . . 34tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 55TASIGNA CAPS 50MG . . . . . . . . . . . . 34TASIGNA CAPS 150MG, 200MG . . . 34tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 48tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 23TAZORAC CREA . . . . . . . . . . . . . . . . . 48TAZORAC GEL . . . . . . . . . . . . . . . . . . . 48taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 44TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 58TECENTRIQ INJ 840MG/14ML . . . . . 34TECENTRIQ INJ 1200MG/20ML . . . 34TECFIDERA CPDR 120MG . . . . . . . . 47TECFIDERA CPDR 240MG . . . . . . . . 47TECFIDERA STARTER PACK . . . . . . 47TECHLITE PEN NEEDLES/ 31G X 6 MM . . . . . . . . . . . . . . . . . . . . . . 60TECHLITE PEN NEEDLES/ 31G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 60TECHLITE PEN NEEDLES/ 32G X 4MM . . . . . . . . . . . . . . . . . . . . . . . 60TECHLITE PEN NEEDLES/ 32G X 6MM . . . . . . . . . . . . . . . . . . . . . . . 60TECHLITE PEN NEEDLES/ 32G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 60TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 23TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 44TEKTURNA HCT . . . . . . . . . . . . . . . . . . 44telmisartan/amlodipine . . . . . . . . . . . . . 42telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg . . . 42telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg . . . . . . . . . . . . . . . . 42telmisartan tabs 20mg, 40mg . . . . . . . 42

sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 24sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 24sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 59sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 19sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 29sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 29sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 29sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 29sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 29sumatriptan succinate tabs . . . . . . . . 29SUPREP BOWEL PREP KIT . . . . . . . 51SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 33SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 32SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 37SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 40SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 40SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 38SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 58SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 56SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 22SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 40SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 40SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 40SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 32SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 56SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 50

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 31tacrolimus caps . . . . . . . . . . . . . . . . . . . 57tacrolimus oint . . . . . . . . . . . . . . . . . . . . 48TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 34

86


Covered Drugs Index

trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 22tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55trimipramine maleate . . . . . . . . . . . . . . 28TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 27tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 55TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 57TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 32tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 55TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 38trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 55tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 55TROGARZO . . . . . . . . . . . . . . . . . . . . . . 38TROPHAMINE . . . . . . . . . . . . . . . . . . . . 49tropicamide . . . . . . . . . . . . . . . . . . . . . . . 60TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 50TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 40TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 58TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 38TURALIO . . . . . . . . . . . . . . . . . . . . . . . . . 34TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 58TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 38tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 34TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 59TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 58TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 47

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 29UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 56UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 34ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 38valacyclovir hydrochloride . . . . . . . . . . 38VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 30valganciclovir . . . . . . . . . . . . . . . . . . . . . . 37

trazodone hydrochloride tabs 300mg . . . . . . . . . . . . . . . . . . . . . . . 27TREANDA INJ 25MG . . . . . . . . . . . . . . 30TREANDA INJ 100MG . . . . . . . . . . . . . 30TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 30TRELEGY ELLIPTA . . . . . . . . . . . . . . . 62TRELSTAR MIXJECT INJ 3.75MG. . 56TRELSTAR MIXJECT INJ 11.25MG . . 57TRELSTAR MIXJECT INJ 22.5MG. . 56treprostinil . . . . . . . . . . . . . . . . . . . . . . . . . 62TRESIBA . . . . . . . . . . . . . . . . . . . . . . . . . 40TRESIBA FLEXTOUCH . . . . . . . . . . . . 41tretinoin caps . . . . . . . . . . . . . . . . . . . . . 34tretinoin crea . . . . . . . . . . . . . . . . . . . . . 48tretinoin gel 0.01% . . . . . . . . . . . . . . . . . 48tretinoin gel 0.05% . . . . . . . . . . . . . . . . . 48tretinoin gel 0.025% . . . . . . . . . . . . . . . 48tretinoin microsphere . . . . . . . . . . . . . . 48tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 48triamcinolone acetonide crea 0.1% . 53triamcinolone acetonide crea 0.025%, 0.5% . . . . . . . . . . . . . . . . 53triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 47triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . 53triamcinolone acetonide lotn . . . . . . . 53triamcinolone acetonide oint . . . . . . . 53triamterene/hydrochlorothiazide . . . . 45triderm crea 0.1% . . . . . . . . . . . . . . . . . 53trientine hydrochloride . . . . . . . . . . . . . 50tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 55trifluoperazine hcl . . . . . . . . . . . . . . . . . . 35trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 38trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 35trihexyphenidyl hydrochloride . . . . . . . 35tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 55tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 55trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 22

TIVICAY TABS 25MG, 50MG . . . . . . . 37tizanidine hcl tabs . . . . . . . . . . . . . . . . . 36tizanidine hydrochloride tabs 4mg . . 36TOBI PODHALER . . . . . . . . . . . . . . . . . 62TOBRADEX OINT . . . . . . . . . . . . . . . . 60tobramycin/dexamethasone . . . . . . . . 60tobramycin nebu . . . . . . . . . . . . . . . . . . 62tobramycin ophthalmic soln . . . . . . . . 21tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 21tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . . 21TOLAK . . . . . . . . . . . . . . . . . . . . . . . . . . . 48tolterodine tartrate . . . . . . . . . . . . . . . . . 51tolterodine tartrate er . . . . . . . . . . . . . . 51topiramate . . . . . . . . . . . . . . . . . . . . . . . . 26toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 33topotecan hcl inj 4mg . . . . . . . . . . . . . . 33toremifene citrate . . . . . . . . . . . . . . . . . . 30TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 57torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 45TOUJEO MAX SOLOSTAR . . . . . . . . 40TOUJEO SOLOSTAR . . . . . . . . . . . . . . 40TPN ELECTROLYTES . . . . . . . . . . . . . 49TRACLEER TABS . . . . . . . . . . . . . . . . 62TRACLEER TBSO . . . . . . . . . . . . . . . . 62TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 40tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 20tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . 20trandolapril tabs 1mg . . . . . . . . . . . . . . 43trandolapril tabs 2mg, 4mg . . . . . . . . . 43tranexamic acid inj . . . . . . . . . . . . . . . . 42tranexamic acid tabs . . . . . . . . . . . . . . 42TRANSDERM-SCOP . . . . . . . . . . . . . . 28tranylcypromine sulfate . . . . . . . . . . . . 27TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 49TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 60trazodone hydrochloride tabs 100mg, 150mg, 50mg . . . . . . . . . 27

87


Covered Drugs Index

VIREAD TABS 150MG, 200MG, 250MG . . . . . . . . . . . 38VITRAKVI CAPS 25MG . . . . . . . . . . . . 32VITRAKVI CAPS 100MG . . . . . . . . . . . 32VITRAKVI ORAL SOLN . . . . . . . . . . . 32VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 34voriconazole inj . . . . . . . . . . . . . . . . . . . 29voriconazole susr . . . . . . . . . . . . . . . . . 29voriconazole tabs . . . . . . . . . . . . . . . . . 29VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 37VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 34VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 50VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 36VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 36vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 55vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55VYTORIN . . . . . . . . . . . . . . . . . . . . . . . . . 45VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 41WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 46wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 34XARELTO STARTER PACK . . . . . . . . 41XARELTO TABS 10MG, 20MG . . . . . 41XARELTO TABS 15MG, 2.5MG . . . . 41XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 57XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 59XIFAXAN TABS 550MG . . . . . . . . . . . . 22XIGDUO XR TB24 5MG; 1000MG . . 40XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 40XOLAIR INJ 75MG/0.5ML . . . . . . . . . . 62XOLAIR INJ 150MG/ML . . . . . . . . . . . 62XOLAIR VIAL INJ 150MG . . . . . . . . . . 62XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 34

venlafaxine hcl er cp24 75mg . . . . . . 28venlafaxine hcl er cp24 150mg . . . . . 28VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 62VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 62verapamil hcl . . . . . . . . . . . . . . . . . . . . . . 44verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . 44verapamil hcl er cp24 200mg . . . . . . . 44verapamil hcl er tbcr . . . . . . . . . . . . . . 44VERAPAMIL HCL SR CP24 360MG . . . . . . . . . . . . . . . . . . 44verapamil hydrochloride inj . . . . . . . . 44verapamil hydrochloride tabs . . . . . . 44VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 36VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 32VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 51V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 60V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 60V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 60VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 51VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 40VIDEX EC CPDR 125MG . . . . . . . . . . 38VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 38vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55vigabatrin pack . . . . . . . . . . . . . . . . . . . 26vigabatrin tabs . . . . . . . . . . . . . . . . . . . . 26vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 26VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 28VIIBRYD STARTER PACK . . . . . . . . . 28VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 26VIMPAT ORAL SOLN . . . . . . . . . . . . . 26VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 26vinblastine sulfate . . . . . . . . . . . . . . . . . 32vincristine sulfate . . . . . . . . . . . . . . . . . . 32vinorelbine tartrate inj 50mg/5ml . . . . 32viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55VIRACEPT TABS 250MG . . . . . . . . . . 38VIRACEPT TABS 625MG . . . . . . . . . . 38VIRAMUNE SUSP . . . . . . . . . . . . . . . . 37VIREAD POWD . . . . . . . . . . . . . . . . . . . 38

valganciclovir hydrochlorde . . . . . . . . 37valproate sodium inj 100mg/ml . . . . . 26valproic acid . . . . . . . . . . . . . . . . . . . . . . . 26valsartan/hydrochlorothiazide . . . . . . 42valsartan tabs 160mg, 40mg, 80mg . . 42valsartan tabs 320mg . . . . . . . . . . . . . . 42vancomycin . . . . . . . . . . . . . . . . . . . . . . . 22vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 5gm, 750mg . . . . 22vancomycin hydrochloride caps 125mg . . . . . . . . . . . . . . . . . . . . . . . 22vancomycin hydrochloride caps 250mg . . . . . . . . . . . . . . . . . . . . . . . 22vancomycin hydrochloride/ dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml . . . 22VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML . . . . . . . . . . . . . . . . . . . 22vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg . . . . . . . 22vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 22vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 22VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 58VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 58VASCEPA CAPS 0.5GM . . . . . . . . . . . 45VASCEPA CAPS 1GM . . . . . . . . . . . . . 45VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 58VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 34VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 32velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 50VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 50VENCLEXTA STARTING PACK . . . . 32VENCLEXTA TABS 10MG . . . . . . . . . 32VENCLEXTA TABS 50MG . . . . . . . . . 32VENCLEXTA TABS 100MG . . . . . . . . 32venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 28venlafaxine hcl er cp24 37.5mg . . . . . 28

88


Covered Drugs Index

zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 25ZORTRESS TABS 0.5MG . . . . . . . . . . 58ZORTRESS TABS 0.25MG . . . . . . . . 58ZORTRESS TABS 0.75MG, 1MG . . . 58ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 58ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 24zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 55ZUBSOLV SUBL 0.7MG; 0.18MG . . 21ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 21ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 34ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 34ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . 36ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . 36ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . 36ZYTIGA TABS 250MG . . . . . . . . . . . . . 30ZYTIGA TABS 500MG . . . . . . . . . . . . . 30

XPOVIO 60 MG ONCE WEEKLY . . . 31XPOVIO 80 MG ONCE WEEKLY . . . 31XPOVIO 80 MG TWICE WEEKLY . . 31XPOVIO 100 MG ONCE WEEKLY . . 31XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 19XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 30XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 41XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

YYERVOY INJ 50MG/10ML . . . . . . . . . 34YERVOY INJ 200MG/40ML . . . . . . . . 34YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 58YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 30YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 30yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 61zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 63ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 34ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 30ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 41zebutal caps 325mg; 50mg; 40mg . . 19ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 34ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 62zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 48ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 51ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46zidovudine caps . . . . . . . . . . . . . . . . . . 38zidovudine syrp . . . . . . . . . . . . . . . . . . . 38zidovudine tabs . . . . . . . . . . . . . . . . . . . 38ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 60ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 36ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 37zoledronic acid inj 5mg/100ml . . . . . . 59ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 32zolpidem tartrate tabs . . . . . . . . . . . . . 63

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, or visit www.CignaHealthSpring.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.© 2018 Cigna 926066 j

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